HSP FORM #1
NORTH CAROLINA PSYCHOLOGY BOARD
895 State Farm Road, Suite 101, Boone, NC 28607
Telephone: (828) 262-2258
DOCUMENTATION OF ORGANIZED HEALTH SERVICES TRAINING PROGRAM
(type or legibly print all information)
Applicant's Name:
Training Site Name and Address:
TO THE APPLICANT: Fill in the above information and forward this form to the organized health services site training
director for his/her completion.
TO THE TRAINING DIRECTOR: After completion, return this form directly to the Psychology Board.
In accordance with G.S. 90-270.20, any licensed psychologist who is qualified by education, who holds permanent licensure
and a doctoral degree, and who provides or offers to provide health services to the public must be certified as a health services
provider psychologist (HSP-P) by the Board.
He alth services in psychology include the diagnosis, evaluation, treatment, remediation, and prevention of: mental, emotional, and
behavioral disorder, disability, and illness; substance abuse ; habit an d con duct disorder; and psych ologica l aspects of p hysical illness,
acciden t, injury, and disability. Included are counseling, psychoeducational, and neuropsychological services related to the above.
H ealth services include collateral contacts by a psychologist with families, caretakers, and other professionals for the purpose of
benefiting a patient or client of that psycholog ist, as well as, direct services by a psycho logist to individuals and group s.
The Board requests your assistance in verifying the following components of the above named applicant's training.
Was the training an internship accredited by the American Psychological Association in Clinical Psychology,
Counseling Psychology, or School Psychology?
Yes
No
If yes, was such full-time
or part-time
? Hours per week
Dates of APA internship: from
(mm/dd/yy) to
(mm/dd/yy)
If the internship was APA accredited, complete the AFFIDAVIT on the back side and return the form to the Board.
If the training was NOT an APA accredited internship, respond to 1-11, complete the AFFIDAVIT on the back
side, and return the form to the Board.
1.
Was the training a planned and directed program in the provision of health services, in contrast to "on the job"
training, and was the trainee provided with a planned, programmed sequence of training experience?
Yes
No
2.
Was there a written statement or brochure describing the training program which was made available to prospective
trainees?
Yes
No
3.
Was the applicant designated as an "intern", "fellow", or "resident", or hold other designation which clearly
indicated training status?
Yes
No
If yes, what was the applicant’s title?
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HSP#1.frm 05/07
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Psychological Associate Applicant Supervised Experience Verification Form - North Carolina Psychology Board
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Pa Doc 3 Psychological - Associate Applicant Program Verification Form - North Carolina Psychology Board
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