Psychological Associate Applicant Supervised Experience Verification Form - North Carolina Psychology Board Page 3
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3F.
If the supervised training experience was completed in North Carolina, did a North Carolina licensed
or certified psychologist or psychological associate, or a psychologist who is exempt from licensure
under N.C.G.S. 902-70.4(b), provide the student with a minimum of one hour per week of individual
face-to-face, regularly scheduled supervision during at least 12 separate weeks of the supervised
training experience, with the specific intent of overseeing the practice of psychology, and health
G Yes
G No
G Not applicable
services, if applicable, rendered by the student?
Provide the name of the supervising psychologist(s): _____________________________________
_______________________________________
If the supervisor(s) was not licensed by the NC Psychology Board, attach documentation of the
supervisor's exemption under G.S. § 90-270.4(b), or if applicable, a copy of the supervisor's current
school psychologist license issued by the Department of Public Instruction.
G.
If the supervised training experience was completed outside of North Carolina, did a licensed or
certified psychologist or psychological associate, or an individual holding a master’s, specialist, or
doctoral degree in psychology, provide the student with a minimum of one hour per week of
individual face-to-face, regularly scheduled supervision during at least 12 separate weeks of the
supervised training experience, with the specific intent of overseeing the practice of psychology, and
health services, if applicable, rendered by the student?
G Yes
G No
G Not applicable
Provide the name of the supervising psychologist(s): _____________________________________
_______________________________________
Attach proof of the supervisor’s license (e.g., copy of license or computer printout of licensing board
verification) or degree program (e.g., copy of supervisor’s graduate transcript) to establish the
supervisor’s training in psychology.
AFFIDAVIT: I certify that I have personal knowledge of the training program evaluated above and that
all answers marked on this form and any other information attached hereto are true and correct to the best
of my knowledge.
Name of person completing this form: _________________________________________
Title: _________________________________________
Address: _______________________________________________________________________________
Telephone Number:______________________ E-mail Address:________________________________
Signature: _____________________________________
Sworn to (or affirmed) and subscribed before me this
_________ day of _____________________, 20____.
______________________________________
My Commission Expires _______________, 20 ____.
Notary’s Signature
SEAL
Page 3 of 3
PADOC#4 12/09
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