Psychoanalysis Form 5 - Application For Limited Permit Page 2
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2Section II: Supervisor’s Certification
A limited permit may be issued to an applicant who has met all requirements for licensure except the licensing examination and/or
experience requirements. The permit is valid for two years and may be extended, at the discretion of the Department, for up to two
additional one-year periods.
The applicant named in Section I is seeking a limited permit to practice as a Psychoanalyst in New York State. Complete the
information below to certify that the applicant will be supervised at the setting named below. Supervision and practice under a
limited permit must be consistent with the requirements for supervised experience in Appendix A. You must also attach a copy of
your license as well as a copy of the operating certificate or certificate of incorporation authorizing the proposed setting to
employ licensed professionals and provide services that are restricted under Title VIII of the Education Law.
Applicant's name: _________________________________________________________________________________________________
(Section I, item 4)
A. I have reviewed Appendix A and I meet the qualifications as a supervisor.
I am a licensed ________________________________________________________________ in _____________________________
Professional Title
State
___________________________________________________________
_______________________________________________
License number (Attach a copy of your license if other than New York)
Date licensed
B. Setting where experience will take place:
_____________________________________________________________________________________________________________
Name of facility (if applicable)
_____________________________________________________________________________________________________________
Street
City
State
Zip Code
The above facility is a (check one and attach a copy of the operating certificate):
Office of Mental Health (OMH) approved facility
Office for People With Developmental Disabilities (OPWDD) approved facility
Office of Alcoholism and Substance Abuse Services (OASAS) approved facility
Department of Health (DOH) approved hospital or nursing home
Office of Children & Family Services (OCFS) approved facility
Public health agency or facility approved by the social services district
Office of a licensed Psychoanalyst (not owned by the applicant)
Office of a licensed physician, clinical social worker, or psychologist (PLLP, PLLC)
Other facility: _______________________________________________________________________________________________
Attestation of Supervisor
I will supervise the permit holder in accordance with the requirements in Appendix A. I declare that the statements made in the foregoing
certification are true, complete and correct. Any false or misleading information in or in connection with this certification may be the cause for
denial of permit and licensure.
Supervisor's signature: ________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print full name: ______________________________________________________________________
Title: ______________________________________________________________________________
Address: ___________________________________________________________________________
___________________________________________________________________________
Phone: ____________________________________ Fax: ____________________________________
E-mail: _____________________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
PO Box 22063, Albany, NY 12201.
Psychoanalyst Form 5, Page 2 of 2, Rev. 8/15
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