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Virginia Board of Psychology
Applications & Forms

The below documents are in Microsoft Word format. If you do not have Microsoft Word, you can get the Microsoft® Word Viewer 97/2000. For PDF files, you'll need the free Adobe Acrobat Reader.

 

Psychologist Forms

Endorsement Forms

Application for Licensure as a Clinical Psychologist by Endorsement (pdf)

Application for Licensure as a School Psychologist by Endorsement (pdf)

Application for Licensure as an Applied Psychologist by Endorsement (pdf)

Licensure/Certification Verification from Another Jurisdiction (pdf)

Areas of Graduate Study (Form 6)

Verification of Active Practice - Clinical Psychologist (pdf)

Verification of Active Practice - School Psychologist (pdf)

Verification of Active Practice - Applied Psychologist (pdf)

 

Examination Forms

Application for Licensure by Examination for Clinical Psychology, School Psychology, or Applied Psychology (pdf)

Application for Registration of Post-Degree Supervision (pdf)

Verification of Post Degree Supervision (Form 3)

Internship Verification (Form 4)

Licensure/Certification Verification from Another Jurisdiction (pdf)

Area of Graduate Study (Form 6)

Licensure Verification for Out-of-State Supervisor (Form 7)

Verification of Pre-Doctoral Supervised Practicum Hours (Form 9)

 

School Psychologist Limited

Application for Licensure as a School Psychologist Limited (pdf)

Employment Verification Form

Licensure/Certification Verification from Another Jurisdiction (pdf)

 

Sex Offender Treatment Providers

Application for Certification as a Sex Offender Treatment Provider Packet (pdf)

Application for Registration of Supervision as a Certified Sex Offender Treatment Provider (pdf)

Application for Add/Change Registration of Supervision as a Certified Sex Offender Treatment Provider (pdf)

Licensure/Certification Verification from Another Jurisdiction (pdf)

Licensure Verification for Out-of-State Supervisor (pdf)

Verification of Post-Degree Supervision (pdf)

Verification of Training (pdf)

Sample of a Sex Offender Treatment Provider Trainee Supervisory Contract (MS Word document)

 

Reinstatement Forms

Application for Reinstatement of a Psychologist License or Certified Sex Offender Treatment Provider, following Disciplinary Action

Application for Reinstatement of a Psychologist License (Clinical, Applied, School) (Not applicable for Psychology temporary COVID licenses.)

Application for Reinstatement of a School Psychologist-Limited License

Application for Reinstatement of Certification as a Sex Offender Treatment Provider

 

Licensee Continuing Education Forms

Continuing Education Experience Summary Form

Form For Reporting Psychology Grand Rounds Attendance

Compliance Forms & Information

Compliance FAQs

Initial Contact Form

Approval Request Report Forms

CE and Education Approval Request

Evaluator Approval Request

Compliance Supervisor Request

Therapist Approval Request

Reports

Employer Notification Form

Group Attendance Report

Physician Prescription Report

Self-Report

Supervisor Report

Therapy Report (Initial)

Therapy Report (Quarterly)

 

Miscellaneous Forms

Name and Address Change Form (pdf)

Request For Verification Of Virginia Psychology License

Request for Change in Status - Current Active to Current Inactive

Request for Change in Status - Current Inactive to Current Active

Request for Change in Status at Renewal - Current Inactive to Current Active

Out-of-state temporary practitioner reporting form

 

Board of Psychology
psy@dhp.virginia.gov

Jaime Hoyle, Executive Director
Susan Brown Wallace, Ph.D., Board Chair