Verification Of Experience Form - California Board Of Psychology
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3VERIFICATION OF EXPERIENCE FORM
To be completed by Primary Supervisor. PLEASE PRINT OR TYPE. When answering questions, pay particular attention to the
time periods of the supervised professional experience.
SECTION I.
SUPERVISEE:
/
/
Last
First
M.I.
Date of Birth
Aliases:
Last
First
M.I.
METHOD OF ACCRUAL OF SUPERVISED PROFESSIONAL EXPERIENCE VERIFIED ON THIS FORM (check one):
c
PSYCHOLOGICAL ASSISTANT REGISTRATION NO.:
c
DEPT. OF MENTAL HEALTH WAIVER
(attach waiver documentation)
c
REGISTERED PSYCHOLOGIST REGISTRATION NO.:
c
ALTERNATIVE SUPERVISION AGREEMENT
c
EXEMPT SETTING
EMPLOYER:
(attach board copy of approval)
c
PSYCHOLOGICAL INTERN
SCHOOL:
c
OUT-OF-STATE EXPERIENCE
STATE:
PRIMARY SUPERVISOR:
Last
First
M.I.
Phone
Address of Record (Street)
City
State Zip
Fax
E-mail
Degree
License Type
License No.
Issue Date
Jurisdiction
(state or province)
Were you licensed in another state during this supervision period? If so, complete the following:
State
License Type
License No.
Issue Date
DELEGATED SUPERVISORS:
Complete the following: For ALL persons providing delegated supervision. List names, license types, license numbers,
and issue dates of license.
NAME
LICENSE TYPE
LICENSE NO.
ISSUE DATE
SECTION II.
DATE OF SUPERVISION:
FROM
TO
Total Number of
Average Number of
Total Hours for
mm / dd / yyyy
mm / dd / yyyy
Weeks Worked:
Hours Worked Per Week:
Entire Period:
DUTIES: Describe below, in detail, the psychological duties included in the supervised professional experience being
verified on this form:
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(Revised 3/15)
P (916) 574-7720
Governor edmund G. Brown Jr
.
1625 N. Market Blvd. N-215, Sacramento, CA 95834
Business, Consumer serviCes And HousinG AGenCy
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