N.H. Admin. Code § Psyc 303.02

Current through Register No. 49, December 5, 2024

Section Psyc 303.02 - Application Process

(a) Persons wishing to obtain licensure as a psychologist in New Hampshire shall apply to the OPLC by submitting the following:

(1) A "Universal Application for Initial Licensure" as described in (d) below, and "Addendum to the Universal Application For Initial Licensure" as described in (c) below;

(2) Supporting documents required of the applicant, as specified in (e) below;

(3) The results of the examination for the professional practice of psychology (EPPP) taken in accordance with Psyc 303.05(b) and submit directly to the OPLC; and

(4) Any fees in accordance with Plc 1002.43 and Plc 1001.08.

(b) Applicant's shall complete and submit the "Universal Application for Initial Licensure" pursuant to Plc 304.03" to the OPLC.

(c) In addition to the application required by (a) above, the applicant shall complete and submit the "Addendum to the Initial Application Required by Plc 304.03" by providing the following:

(1) All names the applicant has ever been known by; and

(2) An answer to the question "In the event of your impairment or death do you have a plan in place for the security of records and the patient accessibility of those records including timeframes for which those records should be kept?".

(d) The applicant for initial licensure shall sign and date the application in accordance with Plc 304.05.

(e) Applicants applying for their initial license shall provide the following supporting documentation in addition to the initial application for licensure as a psychologist described in Psyc 303.02(b):

(1) A "Summary of Supervised Clinical Experience for Internship and Post Doc" form, in which the applicant shall report and submit with the initial applicant for licensure as a psychologist:

a. The applicant's legal name;

b. The applicant's home mailing address;

c. The start and end date of post graduate supervision;

d. The name of the facility where clinical work was performed;

e. The name of the supervisor;

f. The total hours of face-to-face on-site individual and group supervision received;

g. The total hours of clinical experience obtained for each of the following:

1. Predoctoral internship experience of a minimum of 1500 hours; and

2. Postdoctoral experience of a minimum of 1500 hours;

h. The date of conferral of the doctoral degree;

i. The total hours of supervised clinical experience; and

j. The applicant's signature and date of signing below the following attestation:

"I certify that the above information is correct to the best of my knowledge and belief.";

(2) A "Graduate Program Course Sheet" on which the applicant shall provide and submit with the initial application for licensure as a psychologist the following information:

a. Answering yes or no to the question: "Was any part of your graduate study online, telephonic, or other remote learning?";

b. Attaching to the "Graduate Program Course Sheet" documentation that the requirements of Psyc 302.02(b), (c), and (d) were met if the answer to the question in a. above was yes;

c. Answering yes or no to the question on whether the graduate program is APA or CPA approved;

d. Attaching to the "Graduate Program Course Sheet", a one-page verification from the applicant's program's materials, a letter from the program which confirms the status, or a copy from the APA or CPA website page showing accreditation of the program while the applicant was in attendance if the program was accredited;

e. If a graduate program is not APA or CPA accredited attach a separate sheet to the "Graduate Program Course Sheet", and list the course titles and number of credits earned for each of the following if the answer to question in d. above was no:

1. Scientific and professional ethics and standards;

2. Research design and methodology;

3. Statistics;

4. Psychometrics;

5. Psychotherapy techniques;

6. Biological and chemical bases of behavior, including physiological psychology, comparative psychology, neuropsychology, sensation and perception, and psychopharmacology;

7. Cognitive-affective bases of behavior, including learning, thinking, motivation, and emotion;

8. Social bases of behavior, including social psychology, group processes, organization and systems theory, and cultural diversity; and

9. Individual differences, including personality theory, human development, and abnormal psychology; and

f. The total credits earned;

(3) An "Internship Confirmation Form", completed by the applicant and forwarded to the supervisor of the internship experience authorizing the internship program to release all information in their records regarding the applicant to the OPLC;

(4) The "Internship Conformation Form" shall require:

a. The applicants for licensure to provide the following information:

1. The applicant's legal name;

2. The applicant's home mailing address;

3. The applicant's home or cell phone number;

4. The applicant's signature and date of signing below the following authorization:

"I am applying for a license as a psychologist in New Hampshire. The New Hampshire Board of Psychologists requires confirmation of internship supervised clinical experience. This shall serve as your authorization to release any information you have in your files whether favorable or not.";

b. The director of the internship experience to provide the following information:

1. The name of the internship program;

2. The name of the facility;

3. The physical address of the facility;

4. Answer yes or no to the question on whether the program was APA approved at the time the applicant attended;

5. If the answer to iv. above is no, attach a description of the pre doctoral requirements described in Psyc 302.04;

6. Number of interns in training at the same time as the applicant;

7. The applicant's title in the program;

8. The start date and end date the applicant was in the program;

9. Whether the hours of internship experience were full time or part time and the number of hours worked per week;

10. The hours of face-to-face supervision per week;

11. Total supervised face-to-face hours in the time period described in ix. above including individual and group supervision;

12. The number of hours worked per week, the number of weeks worked, and the total number of completed hours worked;

13. The name of the primary supervisor, together with the person's degree status, state licensing status and state license number;

14. Answer yes or no to the question was the internship successfully completed;

15. If the answer to ix. above was no, attach a detailed explanation to the form;

16. Whether the supervisor will recommend licensure without reservation, with reservation, or against license;

17. If the supervisor indicates that their recommendation in xvi. above is with reservation or against licensure attach a detailed explanation;

18. The name of the director;

19. The title of the director at the time of the applicant's attendance at the internship program;

20. The director's academic degree;

21. The address of the director;

22. The director's telephone number and e-mail address of the program;

23. The director's state of licensure and license number; and

24. The director's or supervisor's signature and date of signing below the following attestation:

"I hereby attest that all of the information contained on the form is true and accurate to the best of my knowledge and belief.";

(4) A completed and signed "Postdoctoral Experience Form" that includes the following:

a. In the section to be completed by the applicant the following:

1. The applicant's name;

2. The applicant's phone number;

3. The applicant's home mailing address; and

4. The applicant's signature and dated of signing below the following authorization:

"I am applying for a License as a Psychologist in New Hampshire. The New Hampshire Board of Psychologists requires confirmation of postdoctoral supervised clinical experience. This is your authority to release any information you have in your files, favorable or otherwise."; and

b. The following is to be completed by the supervisor of postdoctoral experience:

1. The name of the post-doctoral program, if applicable;

2. The name of the facility;

3. The address of the facility;

4. Answer yes or no to the question on whether the program APA approved at the time of the applicant's attendance;

5. The applicant's title in the program;

6. The start and end date the applicant was in the postdoctoral program;

7. Whether the applicant's experience was full time or part-time including the hours per week for each;

8. The hours of face-to-face supervision per week and the total during the entire program;

9. The name of the primary supervisor including degree, state license or certificate held, and license or certificate number;

10. Answer yes or no to the question on whether the applicant's post-doctoral experience successfully completed;

11. Whether the reference will recommend licensure without reservation, with reservation, or against license;

12. If the director indicates that their recommendation in xi. above is with reservation or against licensure attach a detailed explanation;

13. The name of the supervisor;

14. The supervisor's title at the time of the program;

15. The supervisor's degree;

16. The address of the program;

17. The telephone number and e-mail address of the program;

18. The supervisor's state of licensure and license number;

19. The supervisor's license or certified field of specialty and issue date; and

20. A signature and date of signing below the following attestation:

"I hereby attest that all of the information contained on the form is true and accurate to the best of my knowledge and belief.";

(5) A completed "Supervisor's Confirmation of Post Doctoral Clinical Experience" form that includes the following:

a. In the section to be completed by the applicant the following:

1. The applicant's legal name;

2. The applicant's home mailing address; and

3. The applicant's signature and date of signing below the following authorization:

"I am applying for a License as a Psychologist in New Hampshire. The New Hampshire Board of Psychologists requires confirmation of postdoctoral supervised clinical experience. This is your authority to release any information you have in your files, favorable or otherwise."; and

b. In the section to be completed by the supervisor the following:

1. The name of the facility where the supervision was provided;

2. The address of the facility;

3. The applicant's title at time of supervision;

4. The start and end dates of the supervised clinical experience;

5. The number of hours worked per week, the number of weeks worked, and the total number of completed hours worked;

6. Hours per week of individual face-to-face supervision;

7. The total hours in time period;

8. The total supervised face-to-face hours in time period in vi. above in including both individual and group supervision;

9. Attach a detailed description of the supervisory methods used, and the types of issues dealt with during supervision including the names and credentials of clinical supervisors other than the supervisor completing the application, if other supervisors are included in the hours documented;

10. Attach a detailed description of the type of work performed by the applicant;

11. Attach a detailed description of the quality of work performed by the applicant;

12. Whether the reference will recommend licensure without reservation, with reservation, or against license:

13. If the supervisor indicates that their recommendation in vii. above is with reservation or against licensure attach a detailed explanation;

14. The supervisor's name;

15. The supervisor's title at the time of supervision;

16. The supervisor's academic degree;

17. The supervisor's address;

18. The supervisor's phone number;

19. The supervisor's e-mail address;

20. The supervisor's state of licensure and license number;

21. The supervisor's license or certification field of specialty and date of issuance; and

22. The supervisor's signature and date of signing below the following attestation:

"I hereby attest that all of the information contained on the form is true and accurate to the best of my knowledge and belief."; and

(6) Three complete separate and distinct "Professional Reference Forms", which shall be submitted in sealed untampered envelopes and one of which shall be completed by a supervisor. All 3 forms shall:

a. Be signed by a person providing a reference;

b. Contain the applicant's printed name and address;

c. Be signed and dated by the applicant, providing a release to the reference to release all pertinent information concerning the applicant to the OPLC;

d. Contain the name, address, phone number, title, degree, and signature of the reference;

e. Indicate the professional relationship to the applicant, including the licensed status and license number of the reference;

f. Indicate the length of time the reference has known the applicant;

g. Describe the reference's knowledge of the applicant's professional and ethical behavior;

h. Include the name of the organization and title of the applicant's position when the reference worked with the applicant;

i. Describe the applicant's duties and responsibilities;

j. Indicate any area where the applicant has a specialty;

k. Indicate whether the reference will attest and certify that the applicant is of good moral character, as defined in Psyc 303.01, and if not, the reasons supporting that conclusion;

l. Explain the circumstances, if applicable, surrounding any of the following of which the reference is aware:

1. Whether the applicant has been or is the subject of any malpractice or civil suit involving the practice of their profession;

2. Whether the applicant has been convicted of a crime in any state or country, the disposition of which was other than acquittal or dismissal;

3. Whether there have been or are any complaints or charges of violation of the ethical codes, professional misconduct, unprofessional conduct, incompetence, or negligence made or pending against the applicant;

4. Whether the applicant has ever been required to surrender their license or certification; and

5. Whether the applicant has been found guilty of, or has entered into a consent decree regarding, a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country by any licensing board or professional ethics body; and

m. Whether the reference will:

1. Make no recommendation of licensure;

2. Recommend licensure "without reservation", or

3. Recommend licensure "with reservation", setting forth in writing the reasons behind that conclusion.

(f) Each applicant for licensure shall submit the following documents in support of their application for licensure:

(1) The results of all criminal background check(s) conducted in each state where the applicant has been a resident since reaching the age of majority;

(2) An original certified transcript, signed, and sealed by the school, of both the undergraduate and graduate courses taken by the applicant, showing dates of attendance, courses taken, grades and class hours earned, programs completed, and degrees awarded by the colleges and universities attended;

(3) The EPPP exam score directly from the association of state and provincial psychology boards (ASPPB);

(4) If the applicant answered yes to the question described in Psyc 303.02(b)(20)a. on the application form, provide a detailed explanation of each conviction and whether the applicant is in compliance with any outstanding court orders for each conviction;

(5) If the applicant answered yes to the questions described in Psyc 303.02(b)(20)e. on the application form, provide a detailed explanation for each yes answer; and

(6) If the applicant answered yes to the question described in Psyc 303.02(b)(2)g. on the application form, provide a copy of any settlement or judgment entered into in the suit(s).

(g) The "Universal Application for Initial Licensure" form and supporting documentation shall:

(1) Be typewritten or legibly printed;

(2) Have all sections complete or designated as not applicable to the applicant; and

(3) Be signed and dated by the applicant in accordance with Plc 304.05.

(h) Any application shall be considered incomplete if:

(1) Any portion of the form is illegible;

(2) Any section of the form is incomplete; or

(3) The form is not signed and dated where required by the applicant.

(i) An application shall be considered to be complete as of the date the following has been received:

(1) A fully completed application form; and

(2) All required supporting documentation specified in Psyc 303.02 (b), (c) and (d).

(j) Within 30 days of the date the application is received the OPLC shall request the applicant to provide any additional information, documentation determined to be needed to clarify the application, or any materials related to the application not submitted.

(k) The OPLC shall approve or deny the application within 60 days of receipt of the completed application described in (i) above.

(l) If the application is denied, the applicant shall be provided an opportunity to request a hearing for reconsideration pursuant to Plc 304.10 on the deficiency issues identified by the OPLC.

N.H. Admin. Code § Psyc 303.02

Derived From Volume XXXVI Number 49, Filed December 8, 2016, Proposed by 12035-B, Effective 11/4/2016, Expires 11/4/2026.

Amended by Volume XL Number 37, Filed September 10, 2020, Proposed by #13089-B, Effective 8/8/2020, Expires 8/8/2030.

Amended by Number 6, Filed February 8, 2024, Proposed by #13845, Effective 3/5/2024, Expires 3/5/2034.