Form Bol - Psy-Se-1 - Application To Supervise A Psychology Service Extender Form printable pdf download

BUREAU OF OCCUPATIONAL LICENSES

STATE OF IDAHO

1109 Main Street, Suite 220

Boise, Idaho 83702-5642

(208) 334-3233

csimpson@ibol.state.id.us

APPLICATION TO SUPERVISE A PSYCHOLOGY SERVICE EXTENDER

An application fee of $50.00 must be submitted with this application.

I hereby submit the following information and make application to supervise a Psychology Service Extender in the State of Idaho

under the provisions of Rule 450, IDAPA 24, Title 12, Chapter 01 and provide the following:

1. Supervisor Full Name _________________________________________________________ License # __________________

2. Mailing address__________________________________________________________________________________________

Street/PO Box

City

State

Zip

3. Daytime phone _(____)________________ Fax _(____)________________

E-mail _______________________________

4. Service Extender Full Name _______________________________________________________________________________

5. Mailing address__________________________________________________________________________________________

Street/PO Box

City

State

Zip

6. Daytime phone _(____)________________ Fax _(____)________________

E-mail _______________________________

7. Initial date of supervisory relationship _______________________ Anticipated duration (in months) __________________

8. Does the service extender hold an Idaho license for a specific profession which requires a master's degree?[ ]Yes

[ ]No

(If Yes, please attach a copy of the license)

9. Does the service extender hold a master's degree from a program in psychology, counseling, or human development?

(If Yes, please attach a copy of the degree)

[ ]Yes

[ ]No

10. Has the service extender previously functioned as a service extender to a licensed psychologist?

[ ]Yes

[ ]No

(If not satisfactorily for at least 20 hours per week over a period of 260 weeks, mark No)

11. Will the service extender receive a minimum 1 hour of supervision for each 20 hours of client contact?

[ ]Yes

[ ]No

(Please complete the Plan for Supervision Addendum on the back)

12. Has the service extender received appropriate preparatory training for the assigned duties?

[ ]Yes

[ ]No

(The Assigned Duties & Preparatory Training Addendum must be completed & attached)

AFFIDAVIT

I hereby certify that the responses provided above and those on the addendum and those attached to this application are true and

accurate to the best of my knowledge and belief. I further certify that I have will comply with the Idaho Laws and Rules governing

the practice of Psychology and the Ethical Principles of Psychologists of the American Psychological Association. I further certify that

I will supervise the work of the service extender named above until such time as I provide written notice by certified mail to the Board

of the termination of my supervision.

I understand that my failure to comply with the rules governing the use of service extenders may result in disciplinary action against

my license.

_______________________________________________________________

Signature of Supervisor

State of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 19 _____.

_______________________________________________________________

(seal)

Notary Public official signature

residing at_______________________________________________________

my commission expires____________________________________________

BOL – PSY-SE-1 - revised 02/00

Form Bol - Psy-Se-1 - Application To Supervise A Psychology Service Extender Form

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