Health Services Provider (Hsp) Application Form - North Carolina
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1
2NORTH CAROLINA PSYCHOLOGY BOARD
APPLICATION FOR HEALTH
895 STATE FARM ROAD, SUITE 101
SERVICES PROVIDER
BOONE, NC 28607
Application Fee: $50.00
(828) 262-2258
Use typewriter or legibly print except for signatures. Return this form, any specified documentation, and
$50.00 check/money order (non-refundable) to the Board at the above address. You will be notified if
additional documentation materials are required. The $50.00 application fee must be remitted with each
application or reapplication for HSP certification.
Name_________________________________________________
Certification Applied For: (Check one)
Mailing Address_________________________________________
Psychologist (permanent)
_________________________________________
Psychologist (provisional)
E-Mail Address _________________________________________
Psychological Associate
Daytime Telephone #: __________________________ License Number (if licensed) ____________________
Check the option under which you are making application for HSP Certification (check only one):
___
A. I am currently approved for listing, or am currently listed, in the National Register of Health Services
Providers in Psychology. Enclose a letter from the National Register as documentation of such.
___
B. I attest that I qualify for listing in the National Register of Health Services Providers in Psychology. I will
forward a letter from the Register as documentation of such within sixty (60) days of the date of this
application (or within 60 days of licensure as a permanently Licensed Psychologist if not yet licensed, but
applying for licensure and certification, at that level).
___
C. I received a doctoral degree from an American Psychological Association accredited program in Clinical
Psychology, Counseling Psychology, School Psychology, or Combined Professional-Scientific Psychology
which included an American Psychological Association accredited internship in a health services setting, and
completed an additional year of supervised experience which meets requirements in 21 NCAC 54 .2704(d).
___
D. I received a doctoral degree from an American Psychological Association accredited program in Clinical
Psychology, Counseling Psychology, School Psychology, or Combined Professional-Scientific Psychology,
completed one year of supervised experience in an organized health services training program which meets
the requirements in 21 NCAC 54 .2704(c) [complete HSP Form #1, which is hyperlinked in Item #7 of the
Instructions for Making Application for Licensure], and completed an additional year of supervised
experience which meets requirements in 21 NCAC 54 .2704(d).
___
E. I have an academic foundation in the provision of health services, completed an internship accredited by the
American Psychological Association, and completed an additional year of supervised experience which meets
requirements in 21 NCAC 54 .2704(d).
___
F. I have an academic foundation in the provision of health services, completed one year of supervised
experience which meets the requirements in 21 NCAC 54 .2704(c) for an organized health services training
program [complete HSP Form #1, which is hyperlinked in Item #7 of the Instructions for Making Application
for Licensure], and completed an additional year of supervised experience which meets requirements in 21
NCAC 54 .2704(d).
Page 1 of 2
HSPApp.frm 12/07
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