4201 Patterson Avenue * Baltimore, MD 21215-2299 410-764-4787
This application is to be used during the COVID -19 pandemic by psychologists who are not licensed in Maryland.
Psychologists must hold an active and in good standing license in another jurisdiction and want to provide services
to their client who is temporarily residing in Maryland due to the pandemic. The application asks for the exception
date/s; however, the Board reserves the right to determine the length of time of the exception. If the client does not
plan to return to the jurisdiction where you are licensed, you will need to apply for a Maryland license to continue
serving that client. If you wish to provide services to NEW clients, you will need to apply for a Maryland license.
The application for licensure as well as Maryland laws and regulations are at
R LEGIBLY PRINT (except for signature) the application. Be sure to provide an email address. All
correspondences from the Board will be by email. All questions on the form MUST be answered. Mail your
completed application, the $100.00 application fee payable to the Board of Psychology, and a copy of your active
psychology license from another jurisdiction (faxes and emails will not be accepted). We will not review
incomplete applications.
1. Full Name: Degree:
2. Home Mailing Address: Telephone:
3. Business Name and Address: Telephone:
4. Preferred Mailing Address: Home
5. Indicate where you hold an active psychology license. Provide proof that your license is in good
standing and there is no pending disciplinary action against your license.
State: License Expiration Date: License #:
6. Have you previously applied for a license to practice psychology in Maryland?
7. Have you ever had a professional license or permit disciplined in any way (e.g., denied, suspended,
reprimanded, censured, restricted, limited, placed on probation, revoked, etc.) by any licensing board
in Maryland or elsewhere, or are you aware of any pending charges or investigations against a
professional license or permit which you hold?
No if yes, provide details on an
attached sheet.
Social Security No:
Page 2
8. Have you ever been convicted of, or entered a plea of guilty or nolo contendere to any felony or misdemeanor
other than a minor traffic violation? Yes No if yes, provide details on an attached sheet.
9. Excluding minor traffic violations, are there any current or pending charges against you in any court of law, or
are you currently released on bond? Yes No if yes, provide details on an attached sheet.
10. Number of current clients to serve
11. Name/s of client/s (optional)
12. Address of at least 1 client client(s)
13. Dates service will be provided ( mm/dd/yy)
14. Check the type of service that will be provided. (check all that apply)
Individual psychotherapy
Psychological Evaluation
15. Have you made a request to provide services in Maryland in the past?
Yes (provide date/s) No
Affidavit: After completing all parts of this application, have the following Affidavit completed by a Notary
Personally appeared before me, and having been duly sworn (or
affirmed), according to law, made the following affidavit, to wit:
I have reviewed a copy of the Maryland Psychology Practice Act which stipulates the requirements for licensure
and practice as a psychologist and agree to abide by the laws and regulations. The standards under which I was
licensed in the jurisdiction indicated on this application form are substantially equivalent to or higher than the
requirements of Title 18 and COMAR 10.36. The signature hereto is my own signature and each and every statement
made in this application was made by me, and is in all respects true and correct to the best of my knowledge and
Notary Seal
Signature of Applicant
Sworn to (or affirmed) and subscribed before me this day of , 20_ .
commission expires , 20
Notary Public