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INSTRUCTIONS FOR COMPLETING THE APPLICATION:Answer INSTRUCTIONS FOR COMPLETING THE APPLICATION:Answer

INSTRUCTIONS FOR COMPLETING THE APPLICATION:Answer - PDF document

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INSTRUCTIONS FOR COMPLETING THE APPLICATION:Answer - PPT Presentation

truthfullyx2014an incomplete application returned to applicantAttach to application instructed space provided sux006600660069cientEmployer to for payable to Board Psychology applicationProspe ID: 405812

truthfully—an incomplete application returned to applicant.Attach to application instructed space provided su�cient.Employer to for payable to Board Psychology application.Prospe

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 CONFIDENTIAL ADDRESS (GfAMRisposto�ceboxormaildroplocation,youmustalsoprovidecon�dentialaddress,Rhecon�dentialaddresscanbeyourbusinessorresidentialaddress,):NumberandStreet Aity State ZipAode 1 Disclosure of your SSN or ITIN is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA 405(c)(2)(C)] authorize collection of your SSN or ITIN. Your SSN or ITIN will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with Section 11350.6 of the Welfare and Institutions Code, or for verication of licensure or examination status by a licensing or examination entity that utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your SSN or ITIN, you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you, and the registration will not be issued. SECTION II: EDUCATION QUALIFICATION This Psychological Assistant application is based upon (Aheckeducationquali�cationattimeofapplication,):Master’sBegree School: AdmissiontoAandidacyforBoctoralBegree BescriptionBegree:(Registrar’sletterrequiredtranscript,) BoctoralBegree BateAwarded/Admitted:An ocial qualifying transcript must be mailed from the graduate institution directly to the Board of Psychology (Board). If using your master’s/doctoral degree to qualify for registration, the transcript must show the degree-awarded date. SECTION III: SUPERVISOR LEGAL NAME OF PRIMARY SUPERVISOR: Last Dirst M,G, Hr,,Sr,,G,GGLicenseNumberC-mailAddressSupervisor is a Licensed Psychologist Board-certied Psychiatrist (check one below): Board-certied in psychiatry by the American Board of Psychiatry and Neurology Board-certied in psychiatry by the American College of Osteopathic Board of Neurology and Psychiatry SECTION IV: LOCATION OF SERVICES Location where the psychological assistant will be providing psychological services: NameofServicesLocationNumberandStreet Aity State ZipAode 2 Additional location of services, if applicable, where the psychological assistant will be providing psychologicalservices (Gfmorethantwolocations,pleaseuseanadditionalsheetofpaper,)NameofNrimarySupervisor LicenseNumberNrimarySupervisor’sNhoneNumber NrimarySupervisor’sC-mailAddressNameofServicesLocation NumberandStreet Aity State ZipAode Note: You must notify the Board of any change or addition of a primary supervisor or location where services are being rendered on form Notication to Add or Change Supervisor or Service Location for a Psychological Assistant. Form can be found on Board’s website at www.psychology.ca.gov SECTION V: PSYCHOLOGICAL ASSISTANT QUESTIONNAIRE Section V to be completed by the prospective psychological assistant. Alearlymarkappropriatecolumn(“yes”“no”)foritembelow,YES Areyoupresentlyregistered,orhaveyoueverbeenregisteredor�ledapplicationtoberegistered,aspsychologicalassistant?If yes, list name(s) of supervisor(s): Areyoucurrentlyregistered,wereyoupreviouslyregistered,orhaveyouever�ledapplicationtoregistertoengageinpsychologicalservicesundersection2909(d)oftheBusinessandNrofessionsAode(registeredpsychologist)?If yes, when? Haveyouever�ledapplicationforlicenseaspsychologistwiththeBoard?If yes, when? Boyouhaveanyproprietaryinterestinthebusinessoftheemployerand/orsupervisor?Boyourent,lease,sublease,orlease-purchaseo�cespacefromtheemployer,supervisor,oranyentityforpurposesoffunctioningaspsychologicalassistant?Boyouhavefamilialand/orinterpersonalrelationshipwiththeemployerand/orsupervisor? 3 Boyoucurrentlyhaveanymentalconditionorchemicaldependencythatinanywayimpairsorlimitsyourabilitytopracticepsychologywithsafetytothepublic?If yes, please explain on a separate sheet of paper. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances,orwereyousoengagedrecentlyenoughsothattheuseofdrugsmayhaveongoingimpactonyourabilitytofunctionaspsychologicalassistant(useofanycontrolledsubstanceasde�nedinBivision10(commencingwithSection11000)oftheHealthandSafetyAode,ordangerousdrug,oranyalcoholicbeveragetoextentorinmannerdangeroustohimselforherself,anyotherperson,orthepublic,ortoextentthatthisuseimpairshisorherabilitytoperformtheworkofpsychologistwithsafetytothepublic)?If yes, please explain on a separate sheet of paper. Section VI to be completed by the prospective supervisor. Alearly mark the appropriate column (“yes” or Haveyoucompletedtherequiredsix-hourcourseinsupervisionwithinthelasttwoyearsasrequiredbyAaliforniaAodeofRegulations(AAR)section1387,1(b)?Boyourent,lease,sublease,orlease-purchaseo�cespacetothepsychologicalassistant?Boyouhavefamilialand/orinterpersonalrelationshipwiththepsychologicalassistant?Uillyouprovideminimumofonehourperweekofindividualface-to-facesupervisiontothepsychologicalassistant?Uillyouinformclientsthatthepsychologicalassistantisunlicensed,andisunderthedirectionandsupervisionofthesupervisorasemployee,inpersonorinwriting,priortotherenderingofservicespursuanttosections1387,1(g)and1391,6AAR?Uillyoubeemployedbythesameworksettingasthepsychologicalassistantandbeavailabletothepsychologicalassistant100percentofthetimethepsychologicalassistantisprovidingpsychologicalservices? 4 SECTION VII: ACKNOWLEDGEMENTS Section VII to be completed by both the prospective psychological assistant and supervisor. Supervisor’s Initials Psychological Assistant’s Initials PLEASE READ EACH STATEMENT BELOW AND INDICATE THAT YOU UNDERSTAND BY PLACING YOUR INITIALS IN THE CORRESPONDING BOX. Both supervisor and psychological assistant must initial each statement. understandthatsupervisorsofpsychologicalassistantsmaynotdelegateanyportionofindividualsupervisiontoanyoneelse,Section 1387(c)(1) Title 16, California Code of Regulations (16 CCR). understandthatnopsychologicalassistantmaybillclientsdirectlyforanyservicesrendered,Section 1387.1(g) 16 CCR. understandthatthepsychologicalassistantshallatalltimesandunderallcircumstancesidentifyhimselforherselftoclientsaspsychologicalassistantofhisorheremployerorresponsiblesupervisorwhenengagedinanypsychologicalactivityinconnectionwiththatemployment,Section 1396.4(b) 16 CCR. understandthateverysupervisorofpsychologicalassistantshallhavetheeducationtrainingandexperienceintheareasofpsychologicalpracticeforwhichtheywillsupervise,andshallberesponsibleforsupervisingthepsychologicalfunctionsperformedbythepsychologicalassistantandensuringthepsychologicalassistantcomplieswiththeprovisionsoftheBusinessandNrofessionsAode,theBoard’sregulations,andtheethicalstandardsestablishedbytheAmericanNsychologicalAssociation,Section 1391.6(a) 16 CCR. understandthatpsychologicalassistantshallbeunderthedirectionandsupervisionoflicensedpsychologistorBoard-certi�edpsychiatristwhoisemployedinthesamesettinginwhichthepsychologicalassistantisemployed,Section 1391.5(a) 16 CCR. understandthatnopsychologicalassistantmaypayfee,monetaryorotherwise,inconsiderationforsupervisionprovided,Section 1391.8(a) 16 CCR. understandthatwithin30daysaftertheterminationoftheemploymentofpsychologicalassistant,thepsychologicalassistantshallnotifytheBoardinwritingofsuchtermination,Section 1391.11 16 CCR. understandthatwithin30daysafteranychangeoradditionofprimarysupervisororinthelocationwhereservicesarebeingrenderedbypsychologicalassistant,thepsychologicalassistantshallnotifytheBoardinwriting,indicatingthee�ectivedateofthechangeoraddition,Dailuretocomplycouldresultinenforcementaction,Section 1391.11 16 CCR. understandthatuponchangeoradditionofprimarysupervisor,newsupervisionagreementisrequiredtobecompletedwiththeprimarysupervisorifintendtoaccruethehoursforsupervisedprofessionalexperiencetowardlicensure,Section 1391.11 16 CCR. understandthatpsychologicalassistantshallnotadvertiseforhisorherservices,includingonanywebsites,Anybusinesscardofpsychologicalassistantmustincludehisorhername,thefactthatheorsheispsychologicalassistant,andincludethenameandlicensenumberofthesupervisorandthelocationwhereservicesareprovided,Sections 1396.4(b) and 1397 16 CCR. understandthatnopsychologicalservicesmaybeprovidedbythepsychologicalassistantpriortotheapprovalofthisapplicationbytheBoard,Business and Professions Code section 2913. understandthatregistrationaspsychologicalassistantshallbelimitedtocumulativetotalofsixyears,Section 1391.1(b) 16 CCR. understandthattheregistrationofpsychologicalassistantexpiresoneyearafterdateofissuanceandthattheregistrationshallberenewedbythatdate,psychologicalassistantwhoseregistrationhasnotbeenrenewedshallnotfunctionaspsychologicalassistant,Registrationsnotrenewedwithin60daysoftheexpirationdatebecomecanceledandnewapplicationmustbesubmitted,alsounderstandthatpsychologicalassistantsmaynotpracticeoraccruehoursofsupervisedprofessionalexperienceduringanyperiodofregistrationdelinquencyorsupervisor’slicensedelinquency,Section 1391.12 16 CCR. understandthatannualreportingisrequiredforpurposesofrenewalforthisregistration,Section 1391.10 16 CCR. NOTICE TO APPLICANT C�ectiveStateBoardCqualizationDranchiseRaxBoardmayshareyourtaxpayerinformationBoard,WouareobligatedtopayyourStateobligation,yourlicensemaystateobligationpaid, 5 SECTION VIII: SIGNATURES Please sign in BLUE ink. I/We declare, under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct. SignatureofNsychologicalAssistantBateSignatureofNrimarySupervisorBateCollection and Use of Personal Information RheBepartmentAonsumerA�airsAaliforniaBoardNsychologycollectinformationrequestedformauthorizedbyNrofessionsAodeSectionsGnformationNracticesAct,Access to Your Information WoumayreviewrecordsmaintainedbyAaliforniaBoardNsychologythatcontainyourinformation,permittedbyGnformationNracticesAct,Seecontactinformationbelow,Possible Disclosure of Personal Information Ueeverye�orttoprotectinformationyouprovideus,However,wemaytoshareinformationyougivegovernmentagencies,Rhismaysharinganyinformationyougaveus,Rheinformationyouprovidemayfollowingcircumstances:GnresponsetoNublicRecordsActrequest,allowedbyGnformationNracticesAct;Rogovernmentagencyrequiredbystatefederallaw;Gnresponsetocourtadministrativeorder,searchwarrant,Contact Information Dornoticeaccesstoyourrecords,youmaycontactAaliforniaBoardNsychologyatNorthMarketBoulevard,SuiteSacramento,AAbyatbye-mailatboplicensing@dca.ca.govDorBepartmentAonsumerA�airs’(Bepartment’s)NrivacyNolicy,youmaycontactBepartmentatNorthMarketBoulevard,Sacramento,AAbyatbye-mailatdca@dca.ca.gov 6 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 (Revised /) (Revised /) INSTRUCTIONS FOR COMPLETING THE APPLICATION: Answertruthfully,Attachtoapplicationinstructedspaceprovidedsu�cient,applicationforpayabletoBoardNsychology,Mailcompleted SECTION I: PERSONAL INFORMATION Gsityourintentiontocountthisexperiencetowardlicensure?WesNoGfyou Last Dirst M,G, Hr,,Sr,,G,GGALIASES Listallothernamesbywhichthepsychologicalassistanthasbeenknown,(Gf Last Dirst M,G, Hr,,Sr,,G,GG Last Dirst M,G, Hr,,Sr,,G,GGADDRESS OF RECORD (AOR) (Rhisispublicinformationandwillbeusedforallcorrespondence,): NumberandStreet Aity State ZipAode C-mailAddress AellNhoneNumber HomeNhoneNumberSocialSecurityNumber(SSN)orGndividualRaxpayerGdenti�cationNumber(GRGN)BateofBirth www.psychology.ca.gov1625 N. Market Blvd. N-215, Sacramento, CA 95834 APPLICATION FOR REGISTRATION AS A PSYCHOLOGICAL ASSISTANT LICENSING UNIT