Hsp Form 1 - Documentation Of Organized Health Services Training Program - North Carolina Psychology Board Page 2
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24.
Was the training completed within 24 months?
Yes
No
Provide dates of training: from _______________ (mm/dd/yy) to _______________ (mm/dd/yy)
5.
Did the training consist of at least 1500 hours of practice?
Yes
No
Provide the number of hours of practice: _________________
6.
Was at least 25% of the training spent in the provision of direct health services to patients or clients seeking
assessment or treatment? (see definition of health services on front)
Yes
No
7.
What percentage of the training was spent in research activities? _________________
8.
Were there a minimum of two doctorally trained licensed, certified, or license eligible psychologist at the training
site as supervisors who had ongoing contact with the trainee?
Yes
No
If yes, provide the names of two supervisors who met this requirement:
1. ______________________________________
2. ______________________________________
9.
Was the training under the direction of a licensed, certified, or license eligible doctorally trained psychologist who
was on staff of the training site, who approved and monitored the training, who was familiar with the training site’s
purposes and functions, and who had ongoing contact with the applicant, and who assumed responsibility for the
quality, suitability, and implementation of the training experience.
Yes
No
If yes, provide the name of that psychologist: ______________________________________________
10.
Did the training provide a minimum of two hours per week of individual face-to-face discussion of the applicant’s
practice, with the specific intent of overseeing the health services rendered by the trainee, with at least 50% of
supervision being provided by licensed, certified, or license-eligible doctorally trained psychologists?
Yes
No
11.
In addition to individual supervision, did the training site provide a minimum of two hours per week of instruction
which was met by group supervision, assigned reading, seminars, and similarly constituted organized training
experiences?
Yes
No
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 and title of person completing form _______________________________________________________
Address: __________________________________________________________________________________
Telephone Number: _______________________________________
Email Address: __________________________________________
Signature: _______________________________________________
Sworn to (or affirmed) and subscribed before me this _________ day of ___________________, 20_______.
_________________________________________________________
ORIGINAL FORM MUST BE
Notary's Signature
RETURNED DIRECTLY
My Commission Expires _________________________________, 20 ______.
TO THE BOARD OFFICE
SEAL
Page 2 of 2
HSP#1.frm 05/07
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