Verification Of Experience Form - California Board Of Psychology Page 2
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3SECTION III. (TO BE COMPLETED BY PRIMARY SUPERVISOR ONLY)
Please answer the following questions as they apply to this supervision experience.
PSYCHOLOGY INTERNSHIPS
Yes
No
(Section 2911, Business and Professions Code)
c
c
1. For experience earned on or after January 1, 2001—Was this internship placement accredited
by the APA, or is it a member of or meets the membership requirements of APPIC or CAPIC?
PSYCHOLOGICAL ASSISTANTSHIPS
(Section 2913, Business and Professions Code)
c
c
1. General question for ALL periods of time—Were you and the supervisee at all times in compliance with
Section 1391 of the California Code of Regulations?
ALL SUPERVISION EXPERIENCES
(Sections 2909(d), 2910, 2911, 2913, Business and Professions Code)
General questions for ALL periods of time:
1. Did you provide at least 1 hour of face-to-face, direct, individual supervision every week?
c
c
c
c
2. Did the supervisee receive supervision for at least 10% of the time worked each week?
c
c
3. Did you and any delegated supervisors possess and maintain a valid, active license during the
entire supervision period?
c
c
4. Was your supervision in compliance with APA Ethical Principles and Code of Conduct
as well as licensing laws and regulations?
5. Did you ensure that the supervisee was at all times in compliance with all applicable licensing laws and regulations?
c
c
c
c
6. Did you and any delegated supervisor have adequate education, training, and experience to
supervise this supervisee’s areas of practice?
c
c
7. Did the supervisee have the appropriate education and training to practice in these areas?
c
c
8. Did you and/or any delegated supervisors receive payment, monetary or otherwise, from the
supervisee for the purpose of providing supervision?
c
c
9. Was the supervisee functioning in this same work setting under any other license or any other
professional capacity with the same client(s) during the period of supervision?
c
c
10. Was your license and/or any delegated supervisor’s license to practice psychology or any other profession subject
to discipline by any state or country during the period of supervision? If yes, explain on a separate sheet of paper.
c
c
11. Prior to or during the period of supervision, did you and/or any delegated supervisor have an
intimate or familial relationship with the supervisee?
12. Was the supervisee a psychotherapy client of yours and/or any delegated supervisor’s prior to or during
c
c
the period of supervision?
General questions for ALL supervision experiences on or after January 1, 2001:
c
c
1. Were you employed at the same work setting where the supervisee was providing psychological services at least
half of the time the supervisee was working?
c
c
2. Were you available to the supervisee 100% of the time the supervisee was working?
c
c
3. Have you and any delegated supervisor completed 6 hours of formal training in supervision pursuant to
California Code of Regulations, Section 1387.1(b) and 1387.2(b)?
c
c
4. Did you inform each client or patient in writing, prior to the rendering of services by the supervisee, that the
supervisee is unlicensed and is functioning under the direction and supervision of yourself and that any fees
paid for services of the supervisee must be paid directly to you or the employer?
c
c
5. Did the supervisee have a proprietary interest in your business and/or the business of any delegated supervisor?
c
c
6. Did the supervisee serve in any capacity that would influence your judgement and/or the judgement of any
delegated supervisor in providing supervision?
General question for ALL supervision experiences prior to January 1, 2001:
c
c
1. Were you engaged in rendering professional services at least 50% of the time in the same work setting in
which the supervisee was obtaining supervised professional experience?
I would rate the supervisee’s performance under my supervision as
satisfactory
unsatisfactory during the period
of supervision.
I declare under penalty of perjury under the laws of the State of California that all the foregoing is true and correct.
Name (Print or Type):
Date
Signature
County/State
(Revised 3/15)
2
15_164
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