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Psychology Licensure App - Florida Board of Psychology

DH-MQA 1187, Revised 4/2022, Rule , Are you an active duty member of the United States Armed Services?Are you a veteran of the United States Armed Services?Are you the spouse of a veteran of the United States Armed Services?Are you the spouse of an active member of the United States Armed Services?If you answered Yes to any of these questions, you may qualify for a reduction inHealth s commitment to serving members and veterans of the United States Armed Forces and their families online at L IIC E NN GSF O R C E SAR MEDDH-MQA 1187, Revised 4/2022, Rule , MQA 1187, Revised 4/2022, Rule 64B19 , Page 3 of 18 Methods of Application Use the information on this page to determine the application method you best qualify for. Examination Application Methods Examination: Requires doctoral degree in Psychology from a program accredited by the american Psychological Association (APA) at the time the applicant was enrolled and graduated.

Examination: Requires doctoral degree in psychology from a program accredited by the American Psychological Association (APA) at the time the applicant was enrolled and graduated. Requires completion of 4,000 hours of supervised experience under a licensed psychologist. The doctoral level internship satisfies the first 2,000 hours.

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Transcription of Psychology Licensure App - Florida Board of Psychology

1 DH-MQA 1187, Revised 4/2022, Rule , Are you an active duty member of the United States Armed Services?Are you a veteran of the United States Armed Services?Are you the spouse of a veteran of the United States Armed Services?Are you the spouse of an active member of the United States Armed Services?If you answered Yes to any of these questions, you may qualify for a reduction inHealth s commitment to serving members and veterans of the United States Armed Forces and their families online at L IIC E NN GSF O R C E SAR MEDDH-MQA 1187, Revised 4/2022, Rule , MQA 1187, Revised 4/2022, Rule 64B19 , Page 3 of 18 Methods of Application Use the information on this page to determine the application method you best qualify for. Examination Application Methods Examination: Requires doctoral degree in Psychology from a program accredited by the american Psychological Association (APA) at the time the applicant was enrolled and graduated.

2 Requires completion of 4,000 hours of supervised experience under a licensed psychologist. The doctoral level internship satisfies the first 2,000 hours. The remaining 2,000 hours must be completed as a post-doctoral resident or fellow according to Board Rule , Florida Administrative Code ( ) and documented on the form provided in this application packet. Passage of the National Examination for Professional Practice in Psychology (EPPP) and the Florida Laws and Rules examination will be required prior to Licensure . Examination w/ Waiver: This application method is for applicants who meet all the requirements for Examination above and have previously passed the EPPP. The Florida Laws and Rules examination will be required prior to Licensure . Bifurcation/Examination: Requires doctoral degree in Psychology from a program accredited by the american Psychological Association (APA) at the time the applicant was enrolled and graduated.

3 Requires completion of 4,000 hours of supervised experience under a licensed psychologist. The doctoral-level internship satisfies the first 2,000 hours. The remaining 2,000 hours must be completed as a post-doctoral resident or fellow according to Board Rule , , and documented on the form provided in this application packet. Applicants approved under this method are able to proceed with sitting for the required examinations while completing the 2,000-hour post-doctoral experience requirement. Verification of the post-doctoral supervised experience and passage of the National Examination for Professional Practice in Psychology (EPPP) and Florida Laws and Rules examinations will be required prior to Licensure . Bifurcation/Examination w/ Waiver: This application method is for applicants who meet all the requirements for Bifurcation/Examination above and have previously passed the EPPP.

4 The Florida Laws and Rules examination will be required prior to Licensure . International Examination: Requires credentials evaluation report verifying the international degree and internship were equivalent to a , , or in Psychology from a Psychology program at an educational institution which meets the criteria of s. (3)(a), Requires letter from a director or former director of an APA-accredited university or college program showing the international program was comparable to an APA-accredited program. Internationally trained applicants able to document post-doctoral experience requirements may apply under this method. Passage of the EPPP and the Florida Laws and Rules examination will be required prior to Licensure . International Bifurcation/Examination: Requires credentials evaluation report verifying the international degree and internship were equivalent to a , , or in Psychology from a Psychology program at an educational institution which meets the criteria of s.

5 (3)(a), Requires letter from a director or former director of an APA-accredited university or college program showing the international program was comparable to an APA-accredited program. Applicants who have not completed the post-doctoral experience requirements may apply under this method. Passage of the EPPP and the Florida Laws and Rules examination will be required prior to Licensure . Endorsement Application Methods Endorsement of Diplomate Status with ABPP: Requires the applicant to possess a current diplomate or specialty certification in good standing with the american Board of Professional Psychology , Inc. (ABPP), at the time the application is submitted to Florida . Information regarding requirements to obtain this credential is available on the organization s website at Refer to section (1)(a), Florida Statutes. Endorsement of 10 Years of Licensed Psychology Experience: Requires the applicant to possess a doctoral degree in Psychology ( , , or ) from a Psychology program which meets the institutional accreditation requirements of s.

6 (3)(b), Must have at least 10 years of experience as a licensed psychologist in any jurisdiction or territory of the United States within the 25 years preceding the date of application. Refer to section (1)(b), Florida MQA 1187, Revised 4/2022, Rule 64B19 , Page 4 of 18 Select one method of Licensure as a Psychologist (2701): $ 1. PERSONAL INFORMATION Address Changes: Notify the Board office immediately of any address change for either practice location or mailing address. If you do not currently have a practice location, inform us as soon as you obtain employment. Licenses are printed with the practice location address but are mailed to your home/mailing address. The internet will display your practice location address only. If none given, your home/mailing address will be displayed.

7 Endorsement Methods Endorsement of Diplomate Status with ABPP Endorsement of 10 Years of Licensed Psychology Experience Examination Methods Examination Examination w/ Waiver Bifurcation/Examination Bifurcation/Examination w/ Waiver International - Examination International - Bifurcation/Examination Application for Licensure as a Psychologist Board of Psychology Box 6330 Tallahassee, FL 32314-6330 Fax: (850) 414-6860 Email: Do Not Write in this Space for Revenue Receipting Only Name: _____ Date of Birth: _____ Last/Surname First Middle MM/DD/YYYY Mailing Address: (The address where mail and your license should be sent) _____ _____ _____ Box Apt. No. City _____ _____ _____ _____ State ZIP Country Home/Cell Telephone Practice Location: (Required if mailing address is a Box- This address will be posted on the Department of Health s website) _____ _____ _____ StreetSuite No.

8 City_____ _____ _____ _____ State ZIP Country Work/Cell Telephone EQUAL OPPORTUNITY DATA: We are required to ask that you furnish the following information as part of your voluntary compliance with 41 CFR Part 60-3-Uniform Guidelines on Employee Selection Procedure (1978); 43 FR 38295 and 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for Licensure . Gender: Male Race: Native Hawaiian or Pacific Islander Hispanic or Latino White Female american Indian or Alaska Native Black or African american Asian Two or More Races Email Notification: To be notified of the status of your application by email, check the Yes box and fill in your email address on the line provided. If you choose to be notified via email you will be responsible for checking your email regularly and updating your email address with the Board office.

9 Yes No Email Address: _____ Under Florida law, email addresses are public records. If you do not want your email address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing. Fees must be paid in the form of a cashier s check or money order, made payable to the Department of Health. An applicant who is denied Licensure or withdraws their application prior to Licensure is entitled to a $ ( Licensure Fee and Unlicensed Activity Fee) refund. Requests to withdraw or for a refund must be made in writing. Fees are refundable for up to three years from the date of receipt. Total fee of $ includes the following: Application Fee $ Licensure Fee $ Unlicensed Activity Fee $ DH MQA 1187, Revised 4/2022, Rule 64B19 , Page 5 of 18 2.

10 SOCIAL SECURITY DISCLOSUREThis information is exempt from public records disclosure. Pursuant to Title 42 United States Code 666(a)(13), the department is required and authorized to collect Social Security numbers relating to applications for professional Licensure . Additionally, section (s.) (1)(a), Florida Statutes ( ), authorizes the collection of Social Security numbers as part of the general licensing provisions. Last Name: _____ First Name: _____ Middle Name: _____ Social Security Number: _____ Social Security Information- * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code 653 and 654; and s. (1), , and , Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure compliance with child support obligations.


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