Fillable IDAHO BOARD OF PSYCHOLOGIST EXAMINERS (State of Idaho)

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IDAHO BOARD OF PSYCHOLOGIST EXAMINERS (State of Idaho)

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BOL – PSY-1 - revised 05/21 1 of 11
IDAHO BOARD OF PSYCHOLOGIST EXAMINERS
Division of Occupational and Professional Therapists
11351 W. Chinden Blvd., Building #6 Boise ID 83714 or
P.O. Box 83720, Boise ID 83720-0063
Phone: (208) 334-3233 Website: https://dopl.idaho.gov
E-mail: psy@dopl.idaho.gov
APPLICATION FOR PSYCHOLOGY LICENSE
Please complete this form by providing the requested information and signing the form. Your signature must be notarized. Applicants are required to
contact the source of the required documentation and request that said documentation be submitted directly to the Board office at the address below.
If the source will not provide the documentation, or the documentation is otherwise unobtainable, please submit a written explanation and any
documents that would assist the Board in reviewing the application. The requirements noted below are for general information only, please refer to
the law and rule listed for complete requirements. Processing will be delayed for applications that do not include a social security number or other
documentation required under Idaho Code § 73-122. Incomplete applications that do not include all the items required (excluding those items
that must be sent directly to our office from an issuing authority) will not be processed and will be returned, which will delay licensure.
There are three avenues to licensure listed below. Please mark on the application which one applies to you.
CHECKLIST FOR APPLICATION BY EXAMINATION/ORIGINAL LICENSE (EPPP Exam/Non-Endorsement): Applicants for whom an
examination may be required. Must have either (1) graduated from an accredited college or university with a doctoral degree in psychology and have
two (2) years of supervised experience acceptable to the Board (one (1) year may include a pre-doctoral practicum or internship and one (1) year
must be post-doctoral), or (2) have graduated from an accredited college or university with a doctoral degree in a field related to psychology, and
provide experience and training acceptable to the Board. (Additional information on qualifications may be found in Idaho Code § 54-2307 and Rules
500 and 550).
Completed application. All requested information must be provided and the form must be notarized.
Proof of age – a clear and readable color copy of a government-issued photo ID such as a passport, military ID, or valid driver’s license is
acceptable.
Copy of legal name change, if applicable (marriage license, divorce decree or court order). This is applicable if the name used on any
accompanying documents, such as transcripts or birth certificate, does not match the name on the application.
Copy of official transcripts, showing the date the doctoral degree was conferred, sent directly to our office from the issuing authority.
Proof of successful passage of the EPPP sent to our office directly from the testing authority.
Verification of Certificate of Professional Qualification, if applicable, must be sent to our office directly from the issuing authority.
Verification of Registration with the National Register of Health Service Providers in Psychology, if applicable, must be sent to our office
directly from the issuing authority.
If you are or have ever been licensed in another state, certification of licensure must be sent to our office directly from the issuing authority.
Additional documentation required if you answered “Yes” to any of questions 19-23. Requirements are listed under each question.
Attach the required fees.
CHECKLIST FOR APPLICATION BY ENDORSEMENT: Applicants who have been licensed or certified by a regulatory board of
psychologists in the United States or Canada for at least five (5) years, where such licensure or certification was based on a doctoral degree.
(Additional information on qualifications may be found in Idaho Code §§ 54-2312 and 54-2307(2) and Rule 250).
Completed application. All requested information must be provided and the form must be notarized.
Proof of age – a clear and readable color copy of a government-issued photo ID such as a passport, military ID, or valid driver’s license is
acceptable.
Copy of legal name change, if applicable (marriage license, divorce decree or court order). This is applicable if the name used on any
accompanying documents, such as transcripts or birth certificate, does not match the name on the application.
Copy of official transcripts, showing the date the doctoral degree was conferred, sent directly to our office from the issuing authority.
Proof of successful passage of the EPPP sent to our office directly from the testing authority.
Verification of Certificate of Professional Qualification, if applicable, must be sent to our office directly from the issuing authority.
Verification of Registration with the National Register of Health Service Providers in Psychology, if applicable, must be sent to our office
directly from the issuing authority.
If you are or have ever been licensed in another state, certification of licensure must be sent to our office directly from the issuing authority.
Five (5) years of documented experience within the previous seven (7) years. This may be letters from employers, supervisors, or colleagues that
provide a statement verifying the practice.
Additional documentation required if you answered “Yes” to any of questions 19-23. Requirements are listed under each question.
Attach the required fees.
BOL – PSY-1 - revised 05/21 2 of 11
APPLICATION FOR PSYCHOLOGY LICENSE
(Continued)
CHECKLIST FOR APPLICATION FOR SENIOR PSYCHOLOGY LICENSURE: Applicants who have maintained a valid psychology license
based on a doctoral degree in the United States or Canada for not less than twenty (20) years, and have practiced psychology for five (5) of the last
seven (7) years immediately prior to the date of application. (Additional information on qualifications may be found in Idaho Code § 54-2312A and
Rule 375).
Completed application. All requested information must be provided and the form must be notarized.
Proof of age – a clear and readable color copy of a government-issued photo ID such as a passport, military ID, or valid driver’s license is
acceptable.
Copy of legal name change, if applicable (marriage license, divorce decree or court order). This is applicable if the name used on any
accompanying documents, such as transcripts or birth certificate, does not match the name on the application.
Verification of Certificate of Professional Qualification, if applicable, must be sent to our office directly from the issuing authority.
Verification of Registration with the National Register of Health Service Providers in Psychology, if applicable, must be sent to our office
directly from the issuing authority.
Proof of meeting the continuing education requirements for the five years immediately prior to this application.
Five (5) years of documented experience within the previous seven (7) years. This may be letters from employers, supervisors, or colleagues that
provide a statement verifying the practice.
If you are or have ever been licensed in another state, certification of licensure must be sent to our office directly from the issuing authority.
Additional documentation required if you answered “Yes” to any of questions 19-23. Requirements are listed under each question.
Attach the required fees.
FEES
EXAM/NON-ENDORSMENT APPLICATION $150.00
ENDORSEMENT APPLICATION $250.00
SENIOR APPLICATION $250.00
ADMINISTRATIVE EXAM $25.00
FEES ARE NOT REFUNDABLE. Please make checks and money orders payable to DOPL. All returned checks are subject to a $20.00 fee and the
application will be invalid.
All applicants must review the Idaho laws and rules prior to licensure. Please note that according to Idaho Code § 54-2303, you must be licensed
to practice. All applicants must certify under oath that they have reviewed and will abide by the laws, rules, and ethics governing the practice of
psychology. The Board’s Laws and Rules may be found at: https://dopl.idaho.gov
.
Please keep a copy of this application for your records.
ATTENTION MEMBERS AND SPOUSES OF MEMBERS OF THE ARMED SERVICES
If you are a member of the armed forces, an honorably discharged veteran or the spouse of an active member or veteran of the military, you are
entitled to certain benefits because of your service. Those benefits may include expedited processing of your application and credit for military
training that is relevant to the occupational license/registration for which you are applying. For a full explanation of eligibility and a comprehensive
description of benefits available, see Idaho Code §§ 67-9401-9407
. Additionally, active members of the military may be eligible for a waiver of
renewal fees and other renewal requirements, see Idaho Code § 67-2602A.
Note: The applicant’s signature must be notarized. The applicants must declare the answers provided are true in front of a notary (jurat).
The language “subscribed and sworn” must appear before the applicant’s signature. An “acknowledgement” where the notary only verifies
the identity of the applicant is not acceptable.
BOL – PSY-1 - revised 05/21 3 of 11
IDAHO BOARD OF PSYCHOLOGIST EXAMINERS
Division of Occupational and Professional Therapists
11351 W. Chinden Blvd., Building #6 Boise ID 83714 or
P.O. Box 83720, Boise ID 83720-0063
Phone: (208) 334-3233 Website: https://dopl.idaho.gov
E-mail: psy@dopl.idaho.gov
APPLICATION FOR PSYCHOLOGY LICENSE
I hereby submit my qualifications and application for a Psychology license in the State of Idaho under the provisions of Title 54,
Chapter 23, Idaho Code, and provide the following:
(Check ONE box for this application type below)
EPPP Exam/Non-Endorsement (if you do not meet the five years of practice for endorsement, or are a first-time applicant
who needs to take the EPPP) Include fees of $150 for the application plus the administrative exam fee of $25, unless you
have already taken and passed the EPPP.
Endorsement (Rule 250) Include fees of $250 for the application.
Senior (Rule 260) Include fees of $250 for the application.
1. Full Name ________________________________________________________________________Ph.D______ Psy.D.______
2. Business Address _________________________________________________________________________________________
(The above address is a public record.) Street/PO Box City State Zip
3. Mailing Address__________________________________________________________________________________________
(This will be used as address of record if none provided above.) Street/PO Box City State Zip
4. Date of Birth _______/_______/_______
mm dd yyyy
(Proof of age – a clear and readable color copy of a government-issued photo ID such as a passport, military ID, or valid driver’s license must be attached.)
5. Social Security No. ______-_____-_______ E-mail ___________________________________________________________
(This is not a public record; required by I.C. § 73-122.) (This is not a public record; required by I.C. § 67-2609.)
6. Business Phone (_____)____________________ Home/Cell Phone (_____)____________________
(This number is a public record.) (This number is not a public record.)
7. Are you or your spouse an active member or honorably discharged veteran of the United States Armed Services?
(To utilize experience or education gained in the military to qualify you for this license, please attach a copy of your DD-214) ( ) Yes ( ) No
8. Attained Baccalaureate degree from ____________________________ on _____________ with Major in ________________
9. Attained Master’s degree from ________________________________ on _____________ with Major in ________________
10. Attained Doctorate degree from _______________________________ on _____________ with Major in ________________
You must document either a doctoral degree in Psychology OR a doctoral degree in a field related to Psychology, which meets the requirements outlined under Rule
500, and complete Addendum 1 & 2. Official university/college transcripts noting that the degree has been conferred must be received by this office directly from the
school registrar.
11. List the department of the university/college awarding the degree noted in item 10. _________________________________
12. List the title of the degree program (e.g. Clinical Psychology; Counseling Psychology; etc.) ____________________________
13. Was the program approved by the A.P.A. at the time the degree was awarded? ( ) Yes ( ) No
14. Please list the name and address of your primary internship supervisor, the beginning & ending dates, and location below:
________________________________________________________________________________________________________
Onset Date Completion Date Internship Site
________________________________________________________________________________________________________
Intern Supervisor Name, Title, and Address
15. At least two (2) years (2000 hours minimum) of documented supervised experience, one (1) year (1000 hours minimum) of
which must be post-doctoral is required for Idaho licensure. Please list the names and addresses of all supervisors below:
_________________________ _________________________ ________________________
Name Name Name
_________________________ _________________________ _________________________
Position & Psychology License Number Position & Psychology License Number Position & Psychology License Number
_________________________ _________________________ _________________________
Current Address Current Address Current Address
_________________________ _________________________ _________________________
City, State, Zip City, State, Zip City, State, Zip
BOL – PSY-1 - revised 05/21 4 of 11
APPLICATION FOR PSYCHOLOGY LICENSE
(continued)
16. Have you ever taken the National Examination for the Professional Practice of Psychology (EPPP)? ( ) Yes ( ) No
(If Yes, we must receive official certification from the interstate reporting service before your application will be processed.)
17. Are you currently or have you ever been licensed in another state?________________________________ ( ) Yes ( ) No
(If Yes, please list state(s). Certification of licensure must be received directly from the issuing authority before your application will be processed.)
18. Do you hold a current Certificate of Professional Qualification OR A registration with the National Register of Health
Service Providers in Psychology; OR A certification by American Board of Professional Psychology from ABPP?
(If Yes, Certification must be received directly from the issuing authority before your application will be processed.) ( ) Yes ( ) No
19. Do you meet the requirements as a Senior Psychologist as outlined in §54-2312A, Idaho Code? ( ) Yes ( ) No
(If Yes, provide proof of meeting the continuing education requirements for the five years immediately prior to this application and provide references under #26
below that can attest to your work experience for five of the last seven years.)
20. Have you ever had a professional license, certification, or registration denied, revoked, suspended or otherwise disciplined
for any reason? ( ) Yes ( ) No
(If Yes, a letter of explanation & a copy of the charges & the final order must be received before your application will be processed.)
21. Have you ever been disciplined due to sexual harassment or sexual misconduct? ( ) Yes ( ) No
(If Yes, a letter of explanation & a copy of the charges & the final order must be received before your application will be processed.)
22. Have you ever voluntarily surrendered a professional license, certification, or registration? ( ) Yes ( ) No
(If Yes, a written explanation of the circumstances surrounding the surrender must be attached.)
23. Have you ever been convicted or entered a plea of guilty, nolo contendere, or no contest to any crime in any jurisdiction?
(Exclude minor traffic offenses but include all misdemeanors, felonies & military court-martials.) ( ) Yes ( ) No
(If yes, the Criminal Conviction Disclosure Form, official court documents, and probation and parole documents along with any other relevant information must
be received with this application.)
24. Have you ever abused, been dependent on, or been treated for the abuse or dependency of alcohol or any controlled
substance? ( ) Yes ( ) No
(If Yes, a detailed statement and any supporting documentation regarding intervention, treatment, and current status must be received before your application will
be processed.)
25. Have you reviewed the Idaho laws and rules governing the practice of psychology? ( ) Yes ( ) No
The laws and rules and review may be found online at https://dopl.idaho.gov.
26. Pl
ease attach the names and current addresses of three (3) persons willing to provide reference regarding your character,
training, and experience.
(We must receive a letter of reference from each person listed before your application will be processed.)
_______
____________________________ ____________________________________ __________________________________
Name Name Name
___________________________________ ____________________________________ __________________________________
Position & License Number Position & License Number Position & License Number
___________________________________ ____________________________________ __________________________________
Current Address Current Address Current Address
___________________________________ ____________________________________ __________________________________
City, State, Zip City, State, Zip City, State, Zip
AFF
IDAVIT
Upon oath I certify each of the following: (1) the responses and information provided in this application and in the
attached addendum(s) and documentation are true and correct to the best of my knowledge; (2) I am the applicant named
in and who has signed this application; (3) I am a United States citizen or a legal permanent resident or I am otherwise
lawfully present in the United States; (4) I have read and will conform to the Laws and Rules governing the profession for
which I am seeking a license or authority to practice; (5) I acknowledge and agree the use of intentional misrepresentation
or fraud in this application or violation of any Laws or Rules governing the profession for which I am seeking a license or
authority to practice shall constitute cause sufficient for denial, suspension, cancellation or revocation of any license or
authority applied for or granted to me; (6) I will provide additional or corrected information if material changes occur
which would cause responses or information provided in or with this application to be inaccurate or incomplete; (7) I
authorize and direct any person, agency, firm, or other entity to release, upon the request of the Idaho Division of
BOL – PSY-1 - revised 05/21 5 of 11
APPLICATION FOR PSYCHOLOGY LICENSE
(continued)
Occupational and Professional Licenses or its authorized representative, any information, communication, report, record,
statement, disclosure, or recommendation that may have bearing on my eligibility for or maintenance of the license or
authority for which I am applying and hereby release and exonerate any of them from any liability of any kind resulting
from the release or collection thereof; and (8) I authorize the Division of Occupational and Professional Licenses to
release to any other regulatory entity in any jurisdiction any information requested about me that may otherwise be
protected or confidential that may have bearing on my eligibility for or maintenance of any license or authority issued or
applied for in this or any jurisdiction and hereby release and exonerate them from any liability of any kind resulting from
the release thereof.
_____________________________________________________
Signature of Applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 20 _____.
______________________________________________________
(seal) Notary Public Official Signature
My Commission Expires___________________________________
BOL – PSY-1 - revised 05/21 6 of 11
APPLICATION FOR PSYCHOLOGY LICENSE
ADDENDUM 1
Please list below the graduate courses you completed which correspond to the basic education in psychology and check the appropriate box for either
semester or quarter hours (see Rule 500.08). (Type or print only) *Does not need to be filled out if the Program is APA approved. See Rule 500.
** Minimal competence is demonstrated by passing a three (3) credit semester graduate course (or a five (5) credit quarter graduate
course) in each of the substantive areas listed below.
Biological Bases of Behavior:
Physiological psychology, comparative psychology, neuropsychology, sensation and perception,
psychopharmacology.
Year
Course Name
Course #
Hours
Earned
Semester
Cognitive-Affective Bases of Behavior: Learning, cognition, motivation, emotion
Year
Course Name
Course #
Hours
Earned
Semester
Social Bases of Behavior: Social psychology, group processes, organizational and systems theory.
Year
Course Name
Course #
Hours
Earned
Semester
Individual Differences: Personality theory, human development, abnormal psychology.
Year
Course Name
Course #
Hours
Earned
Semester
Scientific and Professional Standards and Ethics
Year
Course Name
Course #
Hours
Earned
Semester
BOL – PSY-1 - revised 05/21 7 of 11
Research Design and Methodology
Year
Course Name
Course #
Hours
Earned
Semester
Techniques of Data Analysis: statistics, multivariate statistics, factor analysis, multiple regression, non-parametric statistics.
Year
Course Name
Course #
Hours
Earned
Semester
Psychological Measurement: psychometric principles, test theory, personality assessment, cognitive assessment.
Year
Course Name
Course #
Hours
Earned
Semester
History and Systems of Psychology.
Year
Course Name
Course #
Hours
Earned
Semester
Multiculturalism and Individual Diversity.
Year
Course Name
Course #
Hours
Earned
Semester
BOL – PSY-1 - revised 05/21 8 of 11
IDAHO BOARD OF PSYCHOLOGIST EXAMINERS
Division of Occupational and Professional Licenses
P.O. Box 83720, Boise ID 83720-0063
Phone: (208) 334-3233 Website: https://dopl.idaho.gov
E-mail: psy@dopl.idaho.gov
P
RE-LICENSURE PROFESSIONAL PRACTICE
ACKNOWLEDGEMENT FORM
ADDENDUM 2
A
ll applicants must fit into one of the following categories in order to provide psychological services or practice
psychology without a psychology license. The practice of psychology that does not qualify under one of the following
categories is a serious issue and may constitute a criminal offence. This form refers to the Board Laws and Board Rules
that can be downloaded from our website
https://dopl.idaho.gov. Please indicate your current status (check one):
1. Not practicing psychology at any level in any jurisdiction.
2. Practicing psychology in a jurisdiction (state or province) other than Idaho.
3. Practicing psychology in Idaho under an exempt status consistent with Idaho Code 54-2303 (e.g., a university or a
public mental health agency).
4. Practicing as a Service Extender in Idaho consistent with Rule 450.
5. Intend to practice psychology as a Service Extender in Idaho consistent with Rule 450.
6. Other (explain):
BOL – PSY-1 - revised 05/21 9 of 11
IDAHO BOARD OF PSYCHOLOGIST EXAMINERS
Division of Occupational and Professional Licenses
P.O. Box 83720, Boise ID 83720-0063
Phone: (208) 334-3233 Website: https://dopl.idaho.gov
E-mail: psy@dopl.idaho.gov
Evaluation and Accreditation of Supervised Internship Form
Dear Dr.
Candidate ________________________________________has applied for a license to practice Psychology in the State of Idaho. The
Idaho Board of Psychologist Examiners requires information from you in order to document the candidate's completion of an
internship at an APPIC (Association of Psychology Postdoctoral and Internship Centers) member site or at a site demonstrating an
equivalent program. If your site is an APPIC member, complete only Part 1. If your site is not an APPIC member, complete both Part I
and Part 11 and provide all requested attachments. Thank you for your assistance.
PART I - Completed by all Training Directors
1. Internship Site____________________________________________________________
2. APPIC Member #____________OR Not an APPIC member________
3. Site Address_____________________________________________________________
4. Inclusive dates of candidate's internship: From_______________ To_________________
5. Date Certificate of Internship Completion issued:_______________
6. Training Director's Name__________________________________
__________________________________________________
Training Director's Signature Date
PART 11 - Completed by Directors of non-APPIC member internships only
1. Attach a written description of the planned, programmed sequence of training experiences provided to interns. Include any written
statements or brochures describing the nature of the training program, its goals, the content of the internship, and expectations of
intern performance.
2. List all doctoral level staff psychologists providing supervision to the candidate.
Training Director
a. Name______________________________________
b. Psychology License #_____________State Issuing License____________
c. Mean hours per week at the internship site__________________________
d. Mean hours of supervision each week____________
Second Supervising Psychologist
a. Name_____________________________________
b. Psychology License #__________State Issuing License_____
c. Mean hours per week at be internship site___________
d. Mean hours of supervision provided each week________
(If more than two licensed psychologists supervised the candidate, attach a separate list of those supervisors' names, license numbers,
states issuing licenses, mean hours that supervisor was available on site, & mean hours of supervision provided each week)
3. Provide an attached description of the types of direct (face-to-face) service provided by the intern to consumers of psychological
services.
4. Estimate the percentage of We candidate's time spent providing direct (face-to-face) service to patients/clients
=________________% (i.e. assessment, therapy, or consultation; NOT didactics, research, or support activities)
5. Attach an outline of the didactic activities (case conferences, seminars, in-service training, grand rounds) provided during the
internship, including documentation of the candidate's hours spent in didactic activities during the internship.
6. The total number of interns on site and in training during the inclusive dates of the candidate's internship. Number =____________.
7. The professional title used by interns to represent themselves to the public during the internship. Title =_______________.
8. Attach a copy of the internship's due process procedures for addressing concerns about the intern's performance and the intern’s
concerns about the training program.
9. Total professional hours compiled by the candidate during the inclusive dates of the internship. Hours = _____________ (Include
all internship activities here).
10. Attach copies of all evaluations of the intern’s performance.
__________________________________________________________________
Training Director’s Signature Date
BOL – PSY-1 - revised 05/21 10 of 11
IDAHO BOARD OF PSYCHOLOGIST EXAMINERS
Division of Occupational and Professional Licenses
P.O. Box 83720, Boise ID 83720-0063
Phone: (208) 334-3233 Website: https://dopl.idaho.gov
E-mail: psy@dopl.idaho.gov
EVALUATION AND ACCREDITATION OF SUPERVISED PRACTICE
D
ear Dr.
Candidate ____________________________________________________has applied for a license to
practice Psychology in the State of Idaho. The Idaho Board of Psychologist Examiners requires
information from you in order to evaluate and accredit the extent and quality of the candidate’s supervised
experience. This original form must be completed by the supervisor only and returned directly to the
address noted above. Please provide all information requested. Incomplete information will delay the
processing of the applicant’s file. (Please type or print.)
1. Supervisor name __________________________________________________________________
2. Address _________________________________________________________________________
Street/PO Box City State Zip
3. Supervisor license # ____________________ State issuing license __________________
4. Supervisor area of specialty _________________________________________________________
5. Inclusive dates of candidate’s supervision: From _______________ To __________________
Mm/dd/yy Mm/dd/yy
(Record no more than 1 calendar year per form. Use additional forms for each additional or partial year.)
6. Total hours of supervised practice during dates noted above: ____________
7. Total hours of supervisory one-to-one contact during dates noted above: ___________
8. Name & nature of the setting in which the candidate’s supervised practice took place:
9. D
escribe the nature of the candidate’s duties:
10. State the quality of the candidate’s performance while under your supervision:
11. To your knowledge has disciplinary action been taken against the applicant at any time? ( ) Yes ( ) No
(If Yes, please attach an explanation.)
12. To your knowledge does the applicant have or ever had an addiction to alcohol or any controlled
su
bstance?
( ) Yes ( ) No
(If Yes, please attach an explanation.)
13. To your knowledge has the applicant ever been disciplined because of sexual harassment or sexual
misconduct?
(If Yes, please attach an explanation.) ( ) Yes ( ) No
_________
____________________________________________________________
Signature of Supervisor Date
BOL – PSY-1 - revised 05/21 11 of 11
IDAHO BOARD OF PSYCHOLOGIST EXAMINERS
Division of Occupational and Professional Licenses
P.O. Box 83720, Boise ID 83720-0063
Phone: (208) 334-3233 Website: https://dopl.idaho.gov
E-mail: psy@dopl.idaho.gov
PROFESSIONAL REFERENCE FORM
Candidate _________________________________________has applied for a license to practice Psychology in the State
of Idaho. The Idaho Board of Psychologist Examiners requires information from you in order to evaluate the character,
training, and experience of the candidate. Please complete this form and return it directly to the address noted above.
Please provide all information requested. Incomplete information will delay the processing of the applicant’s file. (Please
type or print.)
1. Reference name _________________________________________________________________________________
2. How long have you known the candidate? ____________________________________________________________
3. Please describe your relationship with the candidate: (check all appropriate boxes)
( ) Colleague ( ) Teacher ( ) Supervisor ( ) Personal acquaintance ( ) Other _______________
4. If you are or were ever an employer, supervisor, or colleague of the candidate, please list the dates of that relationship:
From __________ To _________ AND the candidate’s title/position _____________________ AND
MM/DD/YYYY MM/DD/YYYY
the name of the organization ______________________________________________________________________
5. Please indicate your knowledge of the candidate’s:
Thorough General Little
Knowledge Knowledge Knowledge
Training _______ ________ _______
Work Experience _______ ________ _______
Abilities _______ ________ _______
Personality _______ ________ _______
6. If you can attest to a portion of candidate’s work experience, please list the dates of that experience:
From __________ To _________
MM/DD/YYYY MM/DD/YYYY
7. Do you believe, on the basis of ethical conduct, personal character, technical competence, and professional judgment,
the candidate is a credit to the profession of psychology? ( ) Yes ( ) No
(If No, please explain on a separate sheet)
8. From your knowledge of the candidate, please indicate the area(s) in which the candidate is competent to perform
without supervision: (Please Double check the one main area of competence)
a. ( ) Clinical psychology ( ) Adults ( ) Children
b. ( ) Vocational counseling/guidance: ( ) Adults ( ) Children
c. ( ) Personal problem psychology
d. ( ) Human engineering problem psychology
e. ( ) Industrial problem psychology
f. ( ) Psychological research
g. ( ) Psychological consulting (Please list areas) _________________________________________________
h. ( ) Other _______________________________________________________________________________
9. Name & nature of the setting in which the candidate’s supervised internship took place:
10. Do you have any reservations, not previously mentioned, about fully recommending this candidate for licensure as a
Psychologist? ( ) Yes ( ) No
If Yes, please explain:
11.
___________________________________________________________
Si
gnature Date
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IDAHO BOARD OF PSYCHOLOGIST EXAMINERS (State of Idaho)

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