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New Jersey Ofce of the Attorney General (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6th Floor, P.O. Box 45017
Newark, New Jersey 07101
(973) 504-6470
Dear Applicant:
Recent legislation required the Division of Consumer Affairs to conduct Criminal History
Record Background Checks of all Health Care Professionals prior to the issuance of a license or
permit to practice in a health care profession (N.J.S.A. 45:1-25 et seq.). In order for the Division to
conduct a Criminal History Record Background Check, you must complete the enclosed Certication
and Authorization form and return it to the Board or Committee at the mailing address above.
Upon receipt of the completed Certication and Authorization form, the Board or Committee
will forward to you information you will need to have your ngerprints recorded. The
recording of your ngerprints is necessary to conduct the Criminal History Record Background
Check.
Please note that you will be required to pay a $59.91 fee for this service at the time you schedule
your appointment. Anticipate a minimal wait of four to ve weeks before your permit is approved
or a license is issued.
Sincerely,
State Board of Psychological Examiners
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6th Floor, P.O. Box 45017
Newark, New Jersey 07101
(973) 504-6470
Application for Licensure as a Practicing Psychologist
Date:____________________________
Anonrefundableapplicationlingfeeof$125,intheformofacheckormoneyordermadeouttotheStateofNewJersey,must
besubmittedwiththisapplication.(Applicantsshouldunderstandthatiftheapplicationlingfeeispaidwithapersonalcheck,
andthecheckisreturnedbythebankduetoinsufcientfunds,thenextstepinthelicensureorcerticationprocesswillbedelayed
untilthefeeispaid.)
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinourdirectories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
tothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.
Informationthatyouprovideonthisapplication
maybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Dateofbirth:_________________________
MonthDayYear
 Dr.
Mr.
1. Name Mrs.________________________________________________________________ (_______________________)
 Ms.
Lastname Firstname Middleinitial Maidenname
2. Address
Home:______________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
_____________________________________ ___________________________________
Telephonenumber(includeareacode) E-mailaddress
 Business/Practiceaddress:______________________________________________________________________________
Nameofcompany Telephonenumber(includeareacode)
____________________________________________________________________________________________
Street City State ZIPcode County
 Mailing: ____________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
Attachaclear,full-facepassport-
stylephotograph(2˝x2˝)ofyour
headandshoulders,takenwithin
thepastsixmonths.
A photo is required with each
application.
Donotusestaplestoattachthe
photo.
-1-
3. SocialSecurityNumber
YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosomayresultindenial/nonrenewalof
licensureorcertication.
*SocialSecurityNumber:  __________ -____________ -___________
*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupport
EnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theCommitteeisrequiredto
obtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theCommitteeisalsoobligatedtoprovideyourSocialSecurity
numberto:
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing
compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. ChildSupport
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdmayresultinadenialof
licensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimited
to,immediaterevocationorsuspensionoflicensureorcertication.
 ___________________________________ ___________________________________ ________________________
 
Applicant’sname(pleaseprint) Applicant’ssignature Date
-2 -
click to sign
signature
click to edit
- 3 -
6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous substances. Please read the denitions carefully. Your responses
will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer this question if
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
the application. Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that
you have refused to answer on the basis on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
click to sign
signature
click to edit
7. Haveyoueverbeensummoned;arrested;takenintocustody;indicted;tried;chargedwith; admittedinto pre-trial intervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No
8. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty,
nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury.  Yes No
If “Yes,” provide a copy ofthe judgment of conviction and thereleasefrom parole or probation. Please providea complete
explanation.(Attachadditionalsheetsofpapertothisapplication.)
9. HaveyoupreviouslyappliedforalicenseorcerticateasapracticingpsychologistinNewJersey,anyotherstate,theDistrictof
Columbiaorinanyotherjurisdiction? Yes No
If“Yes,”whenandwhere?_________________________________________________
10. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofanykindinNewJersey,anyotherstate,the
DistrictofColumbiaorinanyotherjurisdiction?  Yes No
If“Yes,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicenseorcerticatewasissuedunder
adifferentname,pleaseproivdethatname.____________________________________________________________________
LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
11. Haveyoueverbeendisciplinedordeniedapsychologist’slicenseorcerticateoranyotherprofessionallicenseinNewJersey,any
otherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
12. Haveyoueverhadaprofessionallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction? Yes No
13. Hasanyaction(includingtheassessmentofnesorotherpenalties)everbeentakenagainstyourprofessionalpracticebyany
agencyorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
14. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofpsychologyorotherprofessionalpracticein
NewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
15. Areyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyanyprofessionalboardin
NewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
16. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction? Yes No
17. Haveyoueverbeensanctionedby,orisanyactionpendingbefore,anyemployer,association,society,orotherprofessionalgroup
relatedtothepracticeofpsychologyorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinany
otherjurisdiction? Yes No
Iftheanswertoanyoftheabovequestions,numbers11through17,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
-4-
Education
1. A)Listalldegreesfromrecognizedcollegesoruniversities.Itisyourresponsibilitytohavethecollegesoruniversitiesforwardto
theBoardthe ofcialtranscriptsof all degrees. If you hold a Certicateof Professional Qualication (C.P.Q.) from the
AssociationofStateandProvincialPsychologyBoards(A.S.P.P.B.),pleasesubmitacopytotheBoard.
College or University Inclusive years Degree, Major Date granted
Diploma or
Certicate
___________________________ _______________ ____________ ___________ _______________________
___________________________ _______________ ____________ ___________ _______________________
___________________________ _______________ ____________ ___________ _______________________
___________________________ _______________ ____________ ___________ _______________________
B)Ofcialtranscriptssentbythecollegeoruniversitygrantingthequalifyingcreditforallgraduatedegreesinpsychologymust
 becomeapartofthisapplication.IfyouholdaC.P.Q.fromtheA.S.P.P.B.,pleasesubmitacopytotheBoard.
Transcripttobesentby:
________________________________________________________________
C)Pleaseattachanabstractofyourdoctoraldissertation(ifany)tothisapplication.
2. Doyouholdadiplomafromanationallyrecognizedpsychologicalboardoragency?
Yes No
If“Yes,”completethefollowing:
 Board Diploma Date granted
________________________________ _______________ _____________________________
________________________________ _______________ _____________________________
________________________________ _______________ _____________________________
________________________________ _______________ _____________________________
Good Moral Character Information
1. Thefollowinghavebeensuppliedwithformstocertifyastomygoodmoralcharacterandhavebeeninstructedtosendthemdirectly
totheBoard.
Name(pleaseprint):__________________________________________________________________________________________
Address: ___________________________________________________________________________________________________


StreetaddressCityStateZIPcode
Name(pleaseprint):__________________________________________________________________________________________
Address: ___________________________________________________________________________________________________


StreetaddressCityStateZIPcode
-5 -

Experience
1. Onlyoneyearofexperiencemaybecountedper12-monthperiod.Foreachpositionindicate:(1)nameofinstitution,company,
agencyorprivatepractice;(2)address;(3)supervisor;(4)applicant’stitle;(5)datesofemployment;(6)totalhoursworkedperweek;
and(7)descriptionofjobfunctionsandresponsibilities.IfyouholdaC.P.Q.fromtheA.S.P.P.B.,pleasesubmitacopytothe
Board.
a.
Nameofinstitution,company,agencyorprivatepractice Streetaddress
City State ZIPcode Telephonenumber(includeareacode)
Name
ofsupervisor Supervisor’stitle Applicant’stitle
Datesofemployment:from to
 Month/Year Month/Year Totalhoursworkedperweek
Descriptionofjobfunctionsandresponsibilities:

c.
Nameofinstitution,company,agencyorprivatepractice Streetaddress
City State ZIPcode Telephonenumber(includeareacode)
Name
ofsupervisor Supervisor’stitle Applicant’stitle
Datesofemployment:from to
 Month/Year Month/Year Totalhoursworkedperweek
Descriptionofjobfunctionsandresponsibilities:

b.
Nameofinstitution,company,agencyorprivatepractice Streetaddress
City State ZIPcode Telephonenumber(includeareacode)
Name
ofsupervisor Supervisor’stitle Applicant’stitle
Datesofemployment:from to
 Month/Year Month/Year Totalhoursworkedperweek
Descriptionofjobfunctionsandresponsibilities:
Ifnecessary,pleaseattachadditionalsheetsofpaperoraresume.
-6-
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
Stateof:_____________________________________________
Countyof:___________________________________________
I, ___________________________________________ ,inmakingthisapplicationtotheStateBoardofPsychological
ExaminersforlicensureorcerticationundertheprovisionsofTitle45oftheGeneralStatutesofNewJerseyandtheRules
oftheStateBoardofPsychologicalExaminers,swear(orafrm)thatIamtheapplicantandthatallinformationprovidedin
connectionwiththisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuracies
orfailuretomakefulldisclosuresmaybedeemedsufcienttodenylicensureorcerticationortowithholdrenewalofor
suspendorrevokealicenseorcerticateissuedbytheBoard.
I further swear(or afrm) that Ihave read N.J.S.A. 45:14B-1 et seq.,togetherwith the Rulesand Regulations of the
StateBoardof PsychologicalExaminers,N.J.A.C.13:42-1.1et seq.,andfullyunderstandthatinreceivinglicensureor
certicationfromtheBoard,Ibindmyselftobegovernedbythem.
Furthermore,I voluntarilyconsentto a thoroughinvestigation of mypresentand pastemploymentand other activities
forthepurposeofverifyingmyqualicationsforlicensureorcertication.Ifurtherauthorizeallinstitutions,employers,
agenciesandallgovernmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,
lesorrecordsrequestedbytheBoard.
_____________________________________________
Applicant’ssignature
Swornandsubscribedtobeforemethis_____________
dayof _________________________ ,____________
MonthYear
Afx Seal Here
_____________________________________________
NameofNotaryPublic(pleaseprint)
_____________________________________________
SignatureofNotaryPublic
} ss.
-7-
click to sign
signature
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signature
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
P.O. Box 45017
Newark, New Jersey 07101
(973) 504-6470
CertifiCAtion And AuthorizAtion form
f
or A CriminAl history BACkground CheCk
Directions:Answerallofthequestionsonthisform.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName
2. Address___________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode
3. Dateofbirth____/____/____ Sex: Male Female
MonthDayYear 
4. SocialSecuritynumber_________/_____ / ________

5. HaveyoucompletedthengerprintingprocessforanyBoard or Committee of the New Jersey Division of Consumer
AffairssinceNovember2003?
Yes No
If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackground
checkprocess.Nopaymentisnecessaryasofnow.
If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:
_______________________________________________ _______________________________________________
BoardorcommitteerequiringthengerprintingMonthandyearyouwerengerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background
checkconductedfortheDepartment of Education, another state agency or anotherstatedoesnotapply)youwillnotbe
requiredtobengerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtime
youapplyforlicensureorcertication.The fee for this service is $18.75.Paymentshouldbemadeintheformofacheckor
moneyorderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.
6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafcoffensessuchasaparkingorspeeding
violationsneednotbelisted.)
Yes No
Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing
orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer
orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted
withthisform.Failure to follow these instructions may result in the denial of an initial application.
Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty
wherethoseorders,disposingoftheconviction,wereissuedandled.
Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee
withinve(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.
Mr.
Mrs.
Ms.
BoardorCommittee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
DualLicense
LicenseType1
________________________
Applicant’sNumber
________________________
LicenseType2
________________________
Applicant’sNumber
________________________
-1 -
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
applicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefull
disclosuresmaybedeemedsufcienttodenycerticationorlicensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicenseissuedbytheBoardorCommittee.
I voluntarily consent toa thorough investigation of my presentand past employment and other activities for the purpose
of verifying my qualications forcertication or licensure.I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requestedbytheBoardorCommittee.
Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
__________________________________________________________ _________________________________

SignatureofapplicantDate
Rev.1/2/19
-2-
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6
th
oor, P.O. Box 45017
Newark, New Jersey 07101
Application for Proposed Supervisors
Name: ____________________________________________________________________________________________
First name Last name Middle initial
Degree: ______________________________________ N.J. License No. __________________________________
Name of Practice (if other then your name): ____________________________________________________________
Address(es) of all practice location(s) - Use additional sheet if necessary:
Address: __________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________ (include area code)
Address: __________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________ (include area code)
Describe the nature of your current practice.
Theoretical orientation: __________________________________________________________________________
______________________________________________________________________________________________
Nature of clientele: ______________________________________________________________________________
______________________________________________________________________________________________
Types of professional services provided: ____________________________________________________________
______________________________________________________________________________________________
Names and permit numbers of all current (not pending) permittees:
Name: ____________________________________________________ No. ________________________________
Name: ____________________________________________________ No. ________________________________
Name: ____________________________________________________ No. ________________________________
Name of your Malpractice Insurance Carrier: ___________________________________________________________
Are your permit holders covered by your policy?
Yes No
Fees - Your usual fee(s) for each of your usual service(s) - specify:
______________________________________________________________________________________________
______________________________________________________________________________________________
Candidate’s name: __________________________________________________________________________________
First name Last name Middle initial
- 1 -
The fee(s) clients will pay for services by the permit holder(s):
__________________________________________________________________________________________________
The fee(s) you will pay the permit holder(s) for services to clients:
__________________________________________________________________________________________________
The fee(s) that will be charged to the permit holder(s) for supervision:
__________________________________________________________________________________________________
Address of the ofce where it is anticipated that permit holder(s) will offer services:
__________________________________________________________________________________________________
Street address City State ZIP code
Will you screen (face-to-face) clients who will be served by permit holder(s)? Yes No
If “No,” describe your alternative screening procedure(s) and the rationale for it (them):
(Pursuant to N.J.A.C. 13:42-3.6 and 13:42-4.4)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Enclose a copy of your current curriculum vitae.
Updated: 1/24/20
- 2 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6
th
oor, P.O. Box 45017
Newark, New Jersey 07101
Certication
I certify that I have read and am familiar with the laws and rules governing the practice of psychology in New
Jersey (N.J.S.A. 45:14B-1 et seq., N.J.A.C. 13:42-1).
I understand that I am primarily responsible for all clients served by permit holder(s) under my supervision; that
I will maintain and retain the originals of all client records and that I will collect all fees for services provided.
I further certify that I will supervise no more that three permit holders at any one time.
I understand and agree that I am to le reports on the work of the permit holder(s) with the Board every six
months for the duration of the supervision.
_____________________________________________ ________________________________
Signature of proposed supervisor Date
(Required by resolution of the State Board of Psychological Examiners, 5-22-95)
Updated: 10/10
- 3 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6
th
oor, P.O. Box 45017
Newark, New Jersey 07101
Supervisory Form for Psychology Candidates
Please print clearly.
Applicant’s name: __________________________________________________________________________________
First name Last name Middle initial
Applicant’s address: ________________________________________________________________________________
Street address City State ZIP code
I. Information About Supervisor
1. Name: _________________________________________________________________________________________
2. Address: _______________________________________________________________________________________
3. Ofce telephone number:___________________________ (include area code)
4. Highest degree earned: _____________________________________________
5. Institution/University and program: _________________________________________________________________
6. Licensed psychologist in New Jersey?
a.
Yes No
b. Year licensed: _______________
c. License number: _____________________
7. Licensed/Certied psychologist in other states
a. State: ________________ _________________ ________________ ______________
b. Year licensed: ________________ _________________ ________________ ______________
c. License number: ________________ _________________ ________________ ______________
d. ABPP diploma? Year: ___________ Specialization: __________________________________________
8. Have you ever been denied a license or had any disciplinary action taken against your license or certicate in
any state or jurisdiction?
Yes No
If “Yes,” please provide details of the denial or disciplinary action, including dates, location and copies of any
documents reecting such denial or disciplinary action.
9. My title and position during the span of supervision was: ______________________________________________
10. Kindly describe your qualications for supervising the particular activities which you supervised for this applicant:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
11. Kindly describe any previous or current relationship you may have had with this applicant:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
II. Information About Supervision
1. The applicant was supervised by me in a facility expressly permitted by law (cf. 45:14B-6).
Yes No
a. Name and address of facility: __________________________________________________________________
- 1 -
b. The applicant’s title (if any) during the time I supervised him/her was: ________________________________
2. The applicant received a temporary permit to work directly under my supervision.
Yes No
Permit No. _______________________________________
3. Inclusive dates of the supervision were:
___________________________________ ___________________________________ ________________
Starting date Completion date Total number of weeks
4. The number of client hours completed by the applicant during the span of my supervision was: _____________
5. The average number of clock hours per week spent with the applicant in face-to-face individual supervisory
activities during the span of my supervision was: ____________________
6. The average number of clock hours per week spent with the applicant in group supervisory activities during the
span of my supervision was: _____________________
7. The average number of clock hours per week spent by the applicant in professional/academic activities associ-
ated with the effective serving of clients (e.g. reviewing case notes, keeping records, reading cases, etc.) during
the span of my supervision was: _____________________
8. Regarding post-doctoral supervision and in accordance with Board Regulations (cf. 13:42-3.6):
a. Did you approve applicant’s clients in advance?
Yes No
b. Were fees for client services either billed by or accepted by the applicant?
Yes No
c. Final professional responsibility for the client’s welfare was mine as supervisor.
Yes No
III. Supervisory Activities
Should the applicant be judged to be in need of further supervised experience, please specify which supervised
activities were used and how often they were used during your period of supervision.
a. Working together with clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
b. Viewing of applicant’s sessions with clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
c. Viewing of videotapes of applicant’s sessions with clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
d. Listening to audiotapes of applicant’s sessions with clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
e. Reacting to case presentations given by applicant
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
f. Conducting role-playing sessions with applicant
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
g. Engaging in problem-solving discussions concerning individual clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
h. Entering into problem-solving discussions concerning applicant’s own problems as they affect work with clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
i. Offering feedback to applicant of specic interventions taken with a client
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
j. Offering feedback on applicant’s interpersonal skills
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
k. Offering feedback on applicant’s personal qualities as they affect work with clients
Very often ______ Often ______ Sometimes ______ Rarely ______ Never______
- 2 -
IV. Supervisor’s Competencies - For the following competencies, kindly indicate at which level the applicant was
performing at the time your supervision ended. Use the following scale.
Level 1 - Ready for independent practice
Level 2 - Needed continued supervision
Level 3 - Had not achieved minimal competence = unsatisfactory
Level 4 - I cannot make a judgment about this competency
a. Ability to establish a professional relationship _______
b. Ability to assess client’s needs and to plan appropriate interventions _______
c. Ability to make interventions appropriate to client needs _______
d. Ability to be exible in choosing and changing interventions as appropriate _______
e. Ability to assess prudently one’s own capacities and skills in a professional situation _______
f. Ability to work effectively in a one-to-one relationship _______
g. Ability to work effectively in a group situation _______
h. Ability to work effectively where systems level interventions are required _______
i. Knowledge of professional ethics and the ability to apply that knowledge appropriately to practical situation. ________
Supervisor’s Conclusion and Recommendations
This applicant is seeking to become a licensed practitioner of psychology in New Jersey. In effect, the applicant is
claiming the readiness for independent professional practice (without supervision). In summary fashion, would you
kindly give us your assessment of the applicant’s current state of preparedness for independent practice, and also
any specic recommendations you may have as to the applicant’s further professional development. Please relate
your remarks to the following areas:
a. Readiness in terms of theoretical knowledge and skills:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
b. Readiness in terms of applied knowledge and skills:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
c. Readiness in terms of personality:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
d. Readiness in terms of ethical practice:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________ ______________________________________
Date Signature of supervisor
Updated 10/10
- 3 -
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6
th
oor, P.O. Box 45017
Newark, New Jersey 07101
Certicate of Good Moral Character
To the Candidate:
Please send one of the two forms provided to someone you wish to use as a reference. It should be completed by
that individual and returned to the Board ofce.
State Board of Psychological Examiners
P.O. Box 45017
124 Halsey Street
Newark, New Jersey 07101
This certies that I am personally acquainted with ______________________________________________________
Print name
of ______________________________________________________________________________________________ ,
Street address City State ZIP code
that I know h _____ to be of good character and hereby recommend h _____ to the State Board of Psychological
Examiners to practice psychology in the State of New Jersey, pursuant to Law.
______________________________________ ______________________________________
Print name Signature
Address ___________________________________________________________________________________________
Street address City State ZIP code
Relationship to applicant ____________________________________
Note: This form cannot be completed by a relative.
- 1 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Psychological Examiners
124 Halsey Street, 6
th
oor, P.O. Box 45017
Newark, New Jersey 07101
Certicate of Good Moral Character
To the Candidate:
Please send one of the two forms provided to someone you wish to use as a reference. It should be completed by
that individual and returned to the Board ofce.
State Board of Psychological Examiners
P.O. Box 45017
124 Halsey Street
Newark, New Jersey 07101
This certies that I am personally acquainted with ______________________________________________________
Print name
of ______________________________________________________________________________________________ ,
Street address City State ZIP code
that I know h _____ to be of good character and hereby recommend h _____ to the State Board of Psychological
Examiners to practice psychology in the State of New Jersey, pursuant to Law.
______________________________________ ______________________________________
Print name Signature
Address ___________________________________________________________________________________________
Street address City State ZIP code
Relationship to applicant ____________________________________
Note: This form cannot be completed by a relative.
- 2 -
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signature
click to edit
- 2 -
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New Jersey Ofce of the Attorney General (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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