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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.

In addition to downloading the forms listed under Psychology Forms, you are required to carefully review the Statutes and Regulations Governing the Practice of Psychology, which can be accessed at this site under Laws and Regulations Governing Psychology. These documents include requirements for licensure in the Commonwealth of Virginia and are to be used as a primary guide.

 

Psychologist Forms

Endorsement Forms

Application for Licensure by Endorsement in Clinical Psychology, School Psychology, or Applied Psychology

Licensure/Certification Verification from Another Jurisdiction (Form 5)

Areas of Graduate Study (Form 6)

EPPP Score Transfer Request Instructions (pdf)

EPPP Score Transfer Request Form (pdf)

Verification of Active Practice

Examination Forms

Application for Licensure by Examination for Clinical Psychology, School Psychology, or Applied Psychology

Application for Registration of Post-Degree Supervision

Verification of Post Degree Supervision (Form 3)

Internship Verification (Form 4)

Licensure/Certification Verification from Another Jurisdiction (Form 5)

Area of Graduate Study (Form 6)

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

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

EPPP Score Transfer Request Instructions (pdf)

EPPP Score Transfer Request Form (pdf)

 

School Psychologist Limited

Application for Licensure as a School Psychologist Limited

Employment Verification Form

Licensure/Certification Verification from Another Jurisdiction

 

Sex Offender Treatment Providers

Application for Certification as a Sex Offender Treatment Provider Packet

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

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

Licensure/Certification Verification from Another Jurisdiction

Licensure Verification for Out-of-State Supervisor

Verification of Post-Degree Supervision

Verification of Training

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)

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

 

Temporary Licenses issued under Executive Order 57

The documents below apply to temporary licenses issued under Executive Order 57.

Licensed Clinical Psychologist

Frequently Asked Questions related to Continuity of Care (pdf)

Executive Order 51

Executive Order 57

Application for Licensure by Endorsement