Psychological Associate Applicant Supervised Experience Verification Form - North Carolina Psychology Board
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3North Carolina Psychology Board
PA DOC #4
895 State Farm Road, Suite 101, Boone, NC 28607
Telephone: (828) 262-2258
PSYCHOLOGICAL ASSOCIATE APPLICANT
SUPERVISED EXPERIENCE VERIFICATION FORM
(type or print all information)
TO THE APPLICANT: Fill in your name and the name and address of your training site and forward the
form to the training site director for completion.
Applicant’s Name: ____________________________________________________________________
Internship, externship, practicum, or other field experience site name and address:
_______________________________________________________________________________
_______________________________________________________________________________
TO THE TRAINING SITE DIRECTOR: In accordance with 21 NCAC 54 .1802(a)(8), a student’s
program shall include internship, externship, practicum, or other field experience which meets specified
criteria. The above named applicant requests your assistance in verifying the following components of the
applicant’s training. After completing ALL items, return this form DIRECTLY to the North Carolina
Psychology Board at the above address.
Did the student complete an internship, externship, practicum, or other field experience at the training site
G Yes
G No
named above?
A.
Was the supervised training experience a planned and directed program of training for the practice of
psychology, in contrast to on-the-job training, and was the trainee provided with a planned and
directed sequence of training integrated with the educational program in which the student was
enrolled?
G Yes
G No
If yes, provide the name of the student’s educational institution and educational program:
Institution: ______________________________
Program: ______________________________
Was this supervised training experience planned by the educational program’s faculty and training site
G Yes
G No
staff, rather than by the student?
B.
Did the supervised training experience have a written description detailing the program of training,
or a written agreement, developed prior to the time of the training, between the student’s educational
program and the training site, which was approved by the student’s educational program prior to its
G Yes
G No
occurrence?
C.
Did the training site have a designated and appropriately licensed or certified psychologist or
psychological associate who was responsible for the integrity and quality of the supervised training
G Yes
G No
experience?
If Yes, provide the name and degree of the psychologist: ____________________________________
Page 1 of 3
PADOC#4 12/09
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