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Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Office Location: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
Fax #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
PSYCHOLOGY EXAMINING BOARD
INSTRUCTIONS FOR PSYCHOLOGY LICENSURE APPLICANTS
AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS (PER METHOD) HAVE
BEEN RECEIVED.
Licensure by Exam (Exam/New Applicant who is at least 18 years old) (Wis. Stat. 455.04(1))
1. Application form (#634) and applicable fees.
2. Conviction record: Subject to Wis. Stat. §§ 111.321, 111.322, and 111.335, applicant does not have a conviction record.
3. Official transcripts: Doctoral degree in psychology (Wis. Stat. § 455.01(2)) from a program accredited by an organization
approved by the examining board, or other academic training that the examining board determines to be substantially
equivalent on the basis of standards in
Wis. Admin. Code § Psy 2.09. (The examining board may require examinations to
determine the equivalence of training for individuals holding doctoral degrees in psychology from non-American
universities.) List all education/training/doctoral degrees on Page 1.
4. Form #2555, Verification of the Supervised Practice of Psychology: At least 1,500 hours of experience in a successfully
completed internship accrued after the completion of all doctoral level coursework.
5. Submit additional Form(s) #2555, as needed (See form instructions for details.): At least 1,500 hours of experience consisting
of any combination of the following, as established by the examining board in Wis. Admin. Code § Psy 2.10.
a. Pre-internship hours that occur after the completion of the first year of the doctoral program or at any time while in a
doctoral program after the completion of a master’s degree in psychology or its equivalent, as defined by the examining
board by rule.
b. Hours accrued in the internship described in Item 4 above that are in excess of the 1,500 hours required in Item 4.
c. Post-internship hours accrued after the completion of the internship in Item 4 above, but before the conferral of the
doctoral degree.
d. Postdoctoral hours obtained after the conferral of the doctoral degree.
6. Examination for Professional Practice in Psychology (EPPP): Passing score on a written examination on the professional
practice of psychology.
7. Wisconsin Jurisprudence Examination: Passing score on a written examination on state law related to the practice of
psychology.
8. License verification(s), if applicable: If you hold or have ever held a mental health related credential in any jurisdiction,
request each jurisdiction to submit a letter of verification directly to the Wisconsin Psychology Examining Board.
9. Form #2252, Convictions and Pending Charges, if applicable.
10. Form #2829, Malpractice Suits and Claims, if applicable.
11. Is name on all credentials the same? If not, submit certified copy of marriage certificate, divorce decree, etc.
12. Applicants for licensure may be required to appear before the examining board in person prior to licensure to allow the
examining board to make such inquiry of them as to qualifications and other matters as it considers proper. If asked to appear,
an additional fee of $266 will be required before the appearance can be scheduled.
Interim Psychologist License: See Form #1634 for further information. (Wis. Stat. 455.04(2))
Reciprocity Applicant must be at least 18 years old and licensed in another jurisdiction. Reciprocity is available if the standards of
the other jurisdiction’s examining board are deemed by members of the Wisconsin examining board to be substantially equivalent to
the standards of this state (Wis. Stat. 455.04(3)). License must remain active until Wisconsin reciprocal credentialing process is
complete.
1. Application form (#634) and applicable fees.
2. Subject to ss. 111.321, 111.322, and 111.335, applicant does not have a conviction record.
3. License verification(s): Applicant must hold an active certificate or license of an examining board of some other state,
territory, foreign country, or province. Request each jurisdiction where you hold or have ever held a mental health related
credential to submit a letter of verification directly to the Wisconsin Psychology Examining Board.
#634 (Rev. 1/2022)
Wis. Stat. ch. 455
i
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Reciprocity (continued)
4. Wisconsin Jurisprudence Examination: Passing score on a written examination on state law related to the practice of
psychology.
5. Form #2252, Convictions and Pending Charges, if applicable
6. Form #2829, Malpractice Suits and Claims, if applicable
7. Is name on all credentials the same? If not, submit certified copy of marriage certificate, divorce decree, etc.
8. Applicants for licensure may be required to appear before the examining board in person prior to licensure to allow the
examining board to make such inquiry of them as to qualifications and other matters as it considers proper. If asked to appear,
an additional fee of $266 will be required before the appearance is scheduled.
Late Renewal (Wisconsin license expired more than 5 years) (Wis. Admin. Code § Psy 4.017(3))
1. Application form (#634) and applicable fees.
2. Subject to ss. 111.321, 111.322, and 111.335, not have a conviction record.
3. Evidence of one of the following:
a. Evidence of an active credential in good standing in another state, or
b. Proof of completion of 80 hours of approved continuing education, including 12 hours of ethics, risk management, or
jurisprudence, within the 2 years preceding the date of application.
4. License verification(s), if applicable: Other than in Wisconsin, if you hold or have ever held a mental health related credential
in any jurisdiction, request each jurisdiction to submit a letter of verification directly to the Wisconsin Psychology Examining
Board.
5. Form #2252, Convictions and Pending Charges, if applicable
6. Form #2829, Malpractice Suits and Claims, if applicable
7. Is name on all credentials the same? If not, submit certified copy of marriage certificate, divorce decree, etc.
8. Applicants for licensure may be required to appear before the examining board in person prior to licensure to allow the
examining board to make such inquiry of them as to qualifications and other matters as it considers proper. If asked to appear,
an additional fee of $266 will be required before the appearance is scheduled.
ii
Committed to Equal Opportunity in Employment and Licensing
#634 (Rev. 1/2022)
Wis. Stat. ch. 455
Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Office Location: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
Fax #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
PSYCHOLOGY EXAMINING BOARD
APPLICATION FOR LICENSURE TO PRACTICE PSYCHOLOGY
The Department must deny your application if you are liable for delinquent state taxes, UI contributions, or child support (Wis. Stat. §§ 440.12 and 440.13).
PLEASE TYPE OR PRINT IN INK
Your name, address, phone number and e-mail address are available to the public. Check box to withhold street
address/PO Box, phone number, and e-mail address from lists of 10 or more credential holders (Wis. Stat. § 440.14).
Last Name
First Name
MI
Former / Maiden Name(s)
Address (street) (city) (state) (zip code)
Daytime Telephone Number
- -
Mailing Address (if different) (street) (city) (state) (zip code)
Date of Birth
/ /
Social Security Number
- -
Your Social Security Number must be submitted with your application on this form. If you do not
have a Social Security Number, you must complete Form #1051
. The Department may not disclose
the Social Security Number collected except as authorized by law.
Ethnicity/gender status information is optional.
GENDER ETHNICITY White, not of Hispanic origin American Indian or Alaskan Hispanic
M F Black, not of Hispanic origin Asian or Pacific Islander Other
Have you ever been licensed in Wisconsin as a Psychologist? Yes No If yes, list your credential number:
School Name
School Address (street, city, state)
Date Degree Conferred Degree Field of Study Date All Degree Requirements Met
School Name (if applicable, attach additional sheets for education if needed) School Address (street, city, state)
Date Degree Conferred Degree Field of Study Date All Degree Requirements Met
APPLICATION FEES: Please check applicable box. Make check payable to DSPS
and attach to this application. To pay by credit card, see Form #3071
.
For Receipting Use Only (57)
I am seeking a Veteran Fee Waiver (for Initial Credential Fee only, see page
2 for further information)
Exam Applicants (EPPP)
Late Renewal after 5 or more yrs
$ 60.00 Initial Credential Fee
$ 60.00 Credential Fee
$ 75.00 State Law Exam
$ 25.00 Late Renewal Fee
$ 15.00 Contract Exam Fee
$ 85.00 Total Fee Attached
$150.00 Total Fee Attached
Reciprocity Applicants Interim Psychologist
$ 60.00 Initial Credential Fee $10.00 Additional non-refundable
$ 75.00 State Law Exam fee (See Form #1634 for
$135.00 Total Fee Attached details.)
Page 1 of 4
Committed to Equal Opportunity in Employment and Licensing
#634 (Rev. 1/2022)
Wis. Stat. ch. 455
Wisconsin Department of Safety and Professional Services
IMPORTANT NOTE: Application is not complete until all of the documents as specified on pages i and/or ii of this form (#634) have been
received.
ARE YOU A VETERAN? If yes, please view the Department website at https://dsps.wi.gov/Pages/Professions/MilitaryLicensureBenefits.aspx for
information and eligibility requirements for veterans, service members, former service members, and their spouses.
If you qualify, are you requesting a waiver of your initial credentialing fee? Yes No
If Yes, provide copy of WI Dept of Veterans Affairs (WDVA) voucher code and list your WDVA Voucher Code #:___________________________
If you qualify, are you requesting equivalency of your military training and experience? Yes No
If Yes, complete and return the Veteran Request Application Addendum (Form #2996). This form must be included with this application.
(You may contact the WDVA at 1-800-947-8387 or dva.wi.gov for assistance in obtaining your WDVA Voucher Code and/or documents
related to your training.)
If you qualify, are you a service member, former service member, or spouse requesting a reciprocal credential? Yes No
If Yes, do not complete this form. You must complete and return the Application for Temporary Spousal Reciprocal License (Form #3982).
CONTINUING EDUCATION AND RENEWAL REQUIREMENTS: Please view the Department website at http://dsps.wi.gov and select
“PROFESSIONS,” then “Psychologist.”
EXPERIENCE AND PRACTICE: (place of current employment)
Employer Name
Location of Employment (Address)
Supervisor Name
Describe your Duties
I AM OR HAVE BEEN LICENSED IN THE FOLLOWING JURISDICTION(S). (Include all active and inactive credentials.)
For each credential listed above, you are required to have each jurisdiction’s board submit a letter of verification directly to the Wisconsin Psychology
Examining Board. The verification letter(s) must state your date of birth, credential number, date of issuance, and a statement regarding disciplinary
actions.
REGARDING THE STATES YOU LISTED ABOVE: Identify the states in which you were licensed by EXAM.
ANSWER THE FOLLOWING QUESTIONS. (Attach additional sheets if necessary.)
1. Have you ever surrendered, resigned, canceled, or been denied a professional license or other credential in Wisconsin, or
any other jurisdiction? If yes, give details on an attached sheet, including the name of the profession and the
agency.
Yes No
2. Have you ever failed to pass any state board examination, national board examination, or EPPP? If yes, provide details
below: (Original pass/fail scores required.)
Yes No
3. Has any licensing or other credentialing agency ever taken any disciplinary action against you, including but not limited
to any warning, reprimand, suspension, probation, limitation, or revocation? If yes, attach a sheet providing details
about the action, including the name of the credentialing agency and date of action.
Yes No
Page 2 of 4
Committed to Equal Opportunity in Employment and Licensing
#634 (Rev. 1/2022)
Wis. Stat. ch. 455
Wisconsin Department of Safety and Professional Services
4. Is disciplinary action pending against you in any jurisdiction? If yes, attach a sheet providing details about pending
action, including the name of the agency and status of action.
Yes No
5. Have you ever been convicted of a misdemeanor, felony, or other violation of federal or state law or do you have any
felony, misdemeanor, or other violation of federal or state law charges pending against you in this state or any other? This
includes convictions resulting from a plea of no contest, a guilty plea, or verdict. If yes, submit Convictions and Pending
Charges Form #2252 and required documentation.
Yes No
6. Are you incarcerated, on probation, or on parole for any conviction? If applicable, attach a sheet providing details
including the terms of incarceration and a copy of a report from your probation or parole officer.
Yes No
7. Have any suits or claims ever been filed against you as a result of professional services? If yes, submit Malpractice Suits
or Claims (Form #2829) and required documentation.
Yes No
8. Are you registered or licensed in any other profession(s)? If yes, state what profession(s) and in what state(s): Yes No
9. Have you ever been credentialed under any other name(s)? If yes, state name(s) credentialed under: Yes No
For the purposes of these questions, the following phrases or words have the following meanings:
"Ability to practice psychology" is to be construed to include all of the following:
1. The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned psychology judgments and to learn and keep abreast of
psychology developments; and
2. The ability to communicate those judgments and psychology information to patients and other health care providers, with or without the use of
aids or devices, such as voice amplifiers; and
3. The physical capability to perform psychology tasks with or without the use of aids or devices, such as corrective lenses or hearing aids.
"Medical Condition" includes physiological, mental, or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech,
and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disability,
emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction and alcoholism.
"Chemical Substances" is to be construed to include alcohol, drugs, or medications, including those taken pursuant to a valid prescription for
legitimate medical purposes and in accordance with the prescriber's direction, as well as those used illegally.
"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 past two years.
"Illegal use of Controlled Dangerous Substances" means the use of controlled dangerous substances 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.
"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 past two years.
"Illegal use of Controlled Dangerous Substances" means the use of controlled dangerous substances 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.
ANSWER THE FOLLOWING QUESTIONS. (Attach additional sheets if necessary.)
10. Do you have a medical condition, which in any way impairs or limits your ability to practice psychology with reasonable
skill and safety? If no, you may skip Questions 11 and 12. If yes, please explain.
Yes No
11. If yes to Question 10, are the limitations or impairments caused by your medical condition reduced or ameliorated because
you receive ongoing treatment (with or without medications) or participate in a monitoring program? If yes, please
explain.
Yes No
12. If yes to Question 10, are the limitations or impairments caused by your medical condition reduced, or ameliorated
because of the field of practice, the setting, or the manner in which you have chosen to practice? If yes, please explain.
Yes No
13. Does your use of chemical substance(s) in any way impair, or limit your ability to practice psychology with reasonable
skill and safety? If yes, please explain.
Yes No
Page 3 of 4
Committed to Equal Opportunity in Employment and Licensing
#634 (Rev. 1/2022)
Wis. Stat. ch. 455
Wisconsin Department of Safety and Professional Services
14. Have you ever been diagnosed as having, or have you ever been treated for pedophilia, exhibitionism, or voyeurism? If
yes, please explain.
Yes No
15. Are you currently engaged in the illegal use of controlled dangerous substances? Yes No
16. If yes to Question 15, are you currently participating in a supervised rehabilitation program or professional assistance
program, which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? If yes, please explain.
Yes No
CERTIFICATION OF LEGAL STATUS:
I declare under penalty of law that I am (check one):
A citizen or national of the United States, or
A qualified alien or nonimmigrant lawfully present in the United States who is eligible to receive this professional license or credential as
defined in the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, as codified in 8 U.S.C.
§1601 et. seq. (PRWORA).
For questions concerning PRWORA status, please contact the U.S. Citizenship and Immigration Services in the Department of Homeland
Security at 1-800-375-5283 or online at http://www.uscis.gov.
Should my legal status change during the application process or after a credential is granted, I understand that I must report this change to the
Wisconsin Department of Safety and Professional Services immediately.
CONTINUING DUTY OF DISCLOSURE:
I understand that I have a continuing duty of disclosure during the application process. If information I have provided in this application becomes
invalid, incorrect, or outdated, I understand that I am obliged to provide any necessary information to ensure the information on my application
remains current, valid, and truthful. I understand that credentialing authorities may view acts of omission as dishonesty and that my duty of disclosure
during the application process exists until licensure is granted or denied.
AFFIDAVIT OF APPLICANT:
I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every respect. I understand
that failure to provide requested information, making any materially false statement and/or giving any materially false information in connection with
my application for a credential or for renewal or reinstatement of a credential may result in credential application processing delays; denial,
revocation, suspension, or limitation of my credential; or any combination thereof; or such other penalties as may be provided by law. I further
understand that if I am issued a credential, or renewal, or reinstatement thereof, failure to comply with the statutes and/or administrative code
provisions of the licensing authority will be cause of disciplinary action.
By signing below, I am signifying that I have read the above statements (Certification of Legal Status, Continuing Duty of Disclosure, and Affidavit
of Applicant) and understand the obligation I have as an applicant or credential-holder should information I have provided to the Department of
Safety and Professional Services change.
Signature: Date:
/ /
(Print and Sign Form)
Page 4 of 4
Committed to Equal Opportunity in Employment and Licensing
#634 (Rev. 1/2022)
Wis. Stat. ch. 455
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Completed 1 February 2022

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