High Desert in Arizona
Forms for Psychologist Applications

Forms for Psychologist Applications

Applicants: 

Download the individual forms below, as needed. The PDFs are form-fillable. Use Adobe Acrobat or Adobe Reader.  Do not use other apps or programs to complete the forms.  Some fields will not be visible in your browser or via another program/app. Forms received in an altered format will be rejected. 

 

  • Core Program Requirements form: (Needed only if your doctoral program is NOT APA or PCSAS accredited.) Upload with your online application where indicated. 
  • Statement of Citizenship or Alien Status Form (SOC):  All applicants are required to complete and submit this form. U.S. citizens must complete Sections I, II and IV.  Citizens of other countries must complete all four sections. This form needs to be uploaded to your online application where indicated.
  • Current Government Issued ID:  Federal and state laws require applicants to provide proof of lawful status in the United States in order to receive a "public benefit" such as a professional license. Not all IDs are the same. See the Evidence List (page 3 of the SOC form) for accepted forms of ID. After uploading the SOC, please use the same upload button to upload a color photo or PDF of an appropriate ID per the evidence list. The upload must be high resolution, in color and readable. 
  • Appropriate Documentation for "YES" Answers:  If you have answered Yes to a professional conduct (declaration) question, additional documentation is required. Download this PDF for a list of the possible declaration questions and the associated documentation or evidence that the applicant must submit to the Board if the applicant’s answer to a declaration question is “yes”. Applications will not be considered administratively complete without these materials. 
  • EPPP Score Transfer:  If you are applying for licensure by Waiver (Exam and/or License Application) or by Credential using the National Register HSP credential, you will need to transfer your EPPP score to Arizona. Please use ASPPB's transfer service, PSY|PRO, to expedite this. See ASPPB's instructions HERE. ASPPB will email your score to [email protected]. This is not needed if you are applying by Credential with the ABPP or CPQ credentials, or for Universal Recognition applications. 


PRIMARY SOURCE VERIFICATIONS (PSVs)

DO NOT submit PSVs with your application.  A PSV is not valid if submitted by an applicant. A PSV must be submitted by the verifier directly to the Board's office in order to be valid.  The verifier must email the verification to [email protected]. The submissions email address is monitored for document submissions only. (For questions, see the Contact Us page for Board staff email addresses.)

USE ADOBE ACROBAT OR ADOBE READER. For the downloadable PDFs below, using any other program or app is likely to result in errors, formatting changes and failure to see and be able to use the digital signature field. DO NOT use DocuSign! This popular app is extremely problematic; the font size of the verifier's answers are very, very small and difficult to read, and end up all over the place, and the formatting of questions and answers usually becomes an unreadable mess. If a form is submitted with formatting changes or is unsigned, it will be rejected, causing unnecessary delays. 

NOTE ABOUT VERIFIERS:  Education and training records for psychologists must be retained permanently. If you are unable to contact your supervisor or director of training, or these psychologists are no longer with your program or training site, you may request the current licensed psychologist in that position who is the current custodian of your training records to complete the verification. If your supervisor or knowledgeable licensed psychologist (current custodian of records) is unavailable, and if your credentials are banked with the Association of State and Provincial Psychology Boards (ASPPB), they may be sent by ASPPB to the Board's office to fulfill this requirement per A.A.C. R4-26-203(C)(4) and (5). The applicant must provide evidence of efforts to locate their supervisors before the Board may accept verifications from ASPPB. 

  • Preinternship/practicum: Supervised Preinternship Experience Summary. (Needed only if you are applying preinternship hours towards licensure.) This is a tool to assist you in completing page 2 of the Supervised Preinternship Experience Verification form, below, and to assist the Board in reviewing your preinternship verification. See online tutorial if you have questions. 
  • Preinternship/practicum: Preinternship Supervised Professional Experience Verification form. 
    • This 3-page PSV is needed only if you are applying preinternship hours towards licensure.
    • If you have multiple preinternship sites, download an additional page 2, below, one for each site. 
    • The applicant needs to fill out page 1 and the first section on each page 2.  See online tutorial if you have questions. 
    • Submit all pages to the verifier (usually your doctoral program's DCT) - pg 1, all copies of page 2, and page 3.   
    • The verifier must fill out the bottom section of each preinternship site page - pg 2, and the 3rd page.  
    • Must be submitted by your doctoral program's director of clinical training directly to the Board's office. May also be submitted by your supervisor if your program is defunct.  
    • Not needed if you have been licensed in another state for 10 years or more - you may waive the requirement to have additional hours verified. 
    • Not needed for the temporary license application. See instructions at the top of this section. 
  • Preinternship/practicum: Preinternship Site - Page 2 (Site page).  Additional Site page(s) will be needed if you are applying preinternship hours towards licensure and have multiple sites. Complete a Site page for each individual site at which you completed a preinternship supervised professional experience. If you have 3 sites, there should be 3 copies of this page, one for each site. One copy is included in the verification, and two additional site pages will be individual PDFs. Complete Section B on the Site page, one Site page for each preinternship site.  See the new online tutorial if you have questions. Your doctoral program's clinical training director needs to complete Section C on each Site page to verify that the information you provided is true and correct according to the training records.

    Do not try to combine the additional Site pages with the Preinternship Verification. It is best if you submit the multiple Site pages as separate PDFs when submitting the verification to your verifier for completion. Combining form-fillable PDFs while the fillable fields are active will cause the data on all Site pages to merge. You will end up with all site pages containing the exact same data.  See instructions at the top of this section regarding submission to the Board's office. 
  • Preinternship Written Training Plans for Each Site:  There is no Arizona form for this requirement. If you are applying preinternship hours towards licensure, a written training plan for each site is required. A written training plan is the contract or agreement between the applicant, the doctoral program and the supervisor(s) at the site, signed and dated prior to the start of the preinternship supervised experience.  It must meet the requirements in A.A.C. R4-26-210(A)(3), including content, goals, objectives, expectations, methods of evaluation, etc.  See the rule referenced in this paragraph for the complete list. If your preinternship or doctoral program lacked written training plan(s), please have your doctoral program's current director of clinical training work with you to create a post-training plan per SPS.01-10. Written Training Plan for Preinternship Supervised Experiences.
  • Internship: Supervised Psychology Internship Verification form.  This PSV is needed if you are applying via the Psychologist Application for Exam and/or Licensure and have been licensed in another state or province less than 20 years. Complete the top portion and submit to your supervisor. The form must be completed by your supervisor and submitted by the supervisor to the Board's office. Email is preferred to [email protected]. See instructions at the top of this section regarding submission to the Board's office. 
  • Postdoc: Postdoctoral Supervised Professional Experience Verification form. This PSV is needed only if you are applying postdoctoral hours towards licensure. Verification of one's postdoctoral supervised professional experience (SPE) hours needs to be for hours that are already completed.  An end date in the future is not possible because the hours haven't yet been completed. The hours and ratios required on the form must be finite, with a specific start and end date. The dates should reflect the period of time in which the hours being verified were worked.  If you have been licensed in another state for 10 years or more, you do not need this form because you may waive the requirement to have additional hours verified. Not needed for supervised temporary license application. See instructions at the top of this section regarding submission to the Board's office. 
  • Postdoctoral Written Training Plan:  There is no Arizona form for this requirement. If you are applying postdoc hours towards licensure, or submitting a Supervised Temporary License application, a copy of the postdoc written training plan is required. A written training plan is the contract or agreement between the applicant and their supervisor and postdoctoral training program which was signed and dated prior to the start of the supervised experience.  It must meet the requirements in A.A.C. R4-26-210(D), including content, goals, objectives, expectations, methods of evaluation, etc. See the rule referenced in this paragraph for the complete list.  If your postdoc lacked a written training plan altogether, please have your supervisor work with you to create a post-experience training plan per SP.01-14: Written Training Plan for Postdoctoral Supervised Experiences. 
  • License Verifications: Verification of Licensure is required from every jurisdiction (U.S. state, district, territory or Canadian province) that has ever issued the applicant a license, registration and/or certification for any profession, regardless of current status (active, inactive, expired, revoked, surrendered, or otherwise). 
    • A form is NOT provided for license verifications, which are PSVs.  Many boards, including Arizona's Board of Psychologist Examiners, no longer produce written PSVs of licensure separate from their online license lookups or licensee search pages. If any of your other licensing Boards have an online license lookup  that states it is a "primary source verification", you may upload a screenshot or PDF of the online verification at the appropriate point in your application. If the primary source verification statement is on a separate page of that Board's website, please include a PDF or screenshot of this statement with the verification. (Use a Snip tool/app to take a screenshot, paste it into a Word document, repeat as needed if the PSV statement is on a separate web page, then print to PDF. ) No explanation is needed regarding this. Board staff is aware of this trend and knows to look for the primary source verification statement when these are uploaded. 
    • For PSV of licensure, the verification must state if there have been disciplinary actions taken against the license, or not.  If there are no actions, it is not enough to have nothing listed. There must be an unequivocal statement that there have been no actions. For this Board, the online verification states "Board Actions" and "None" or it will list details and a downloadable PDF copy of the action(s).  California's verification letter has a sentence that states in their own words that no actions have been preferred against the license. Every state has its own way to say it, but it must be included for it to be a PSV that meets requirements for a license application. 
    • If any of your other licensing Boards do not have the PSV statement on their online license lookups/licensee searches, or do not include a statement regarding the status of Board actions, applicants are responsible to contact their licensing Boards to request that verification of the license be sent to the Arizona Board. Each state has their own requirements for how to make this request. The applicant is responsible for any fees incurred. 

    • Make sure to include ALL U.S. states, districts and territories, as well as any Canadian provinces in which you hold or have ever held a license (certification, registration, etc.) regardless of current status of that license, in the applicable fields of the online application. Failure to do so is considered unprofessional conduct per A.R.S. § 32-2061(16) (and possibly other violations) and historically has resulted in denial of the application or disciplinary action against the Arizona license, up to and including revocation.  

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