Source: https://psychboard.az.gov/r4-26-301?page=1
Timestamp: 2020-08-15 02:58:21
Document Index: 521053

Matched Legal Cases: ['§ 32', '§ 32', '§ 41', '§ 32', '§ 32', '§ 32', '§ 32', '§ 32']

R4-26-301 | Arizona Board of Psychologist Examiners
A. An individual who wishes to be licensed as a psychologist shall submit an application packet to the Board that includes an application form, which is available from the Board office and on its website, with an attestation that is signed and dated by the applicant, and provide the following:
c. Residential address and telephone number;
d. Business name and address;
e. Work telephone and fax numbers;
f. E-mail address;
g. Gender;
h. Date of birth;
i. Place of birth; and
j. Social Security number;
a. Holds a Certificate of Professional Qualification in Psychology, a National Register of Health Service Providers in Psychology credential, or is a diplomate or specialist of the American Board of Professional Psychology;
b. Is or ever has been licensed as a psychologist in another regulatory jurisdiction and if so, the name of the regulatory jurisdiction and license number;
c. Has applied for and been rejected or denied licensure as a psychologist in a regulatory jurisdiction and if so, the name of each regulatory jurisdiction, date of each application, and reason given for the rejection or denial;
d. Is or ever has been licensed or certified in a profession or occupation other than psychology and if so, the names of the professions or occupations, regulatory jurisdictions, and license numbers;
e. Has ever taken the national examination and if so, the name of each regulatory jurisdiction in which the examination was taken and each date of examination;
f. Has ever had an application for a professional license, certification, or registration other than psychology denied or rejected by a regulatory jurisdiction and if so, the name of the regulatory jurisdiction, type of license, certification, or registration denied or rejected, and date of denial or rejection;
g. Has ever withdrawn an application for a professional license, certification, or registration in lieu of administrative proceedings and if so, the reason for the withdrawal;
h. Has ever had disciplinary action initiated against the applicant’s professional license, certification, or registration, or had a professional license, certification, or registration suspended or revoked by a regulatory jurisdiction and if so, the name of the regulatory jurisdiction, date of the disciplinary action, and license number;
i. Has ever entered into a consent agreement or stipulation arising from a complaint against any professional license, certification, or registration and if so, the name of the regulatory jurisdiction, date, and license number;
j. Is a member of any professional association in the field of psychology and if so, name of the association;
k. Has ever had membership in a professional association in the field of psychology denied or revoked and if so, the name of the professional association and date of denial or revocation;
l. Is currently under investigation for or has been found guilty of violating a code of professional ethics of any professional organization and if so, the name of the professional organization and date of investigation;
m. Is currently under investigation for or has been found to have violated a professional code of conduct by a regulatory jurisdiction and if so, the name of the regulatory jurisdiction and date of investigation;
n. Has ever been sanctioned or placed on probation by a regulatory jurisdiction and if so, the name of the regulatory jurisdiction and date of action;
o. Is currently awaiting trial, has been convicted of, or pled no contest or guilty to any felony or a misdemeanor other than a minor traffic offense (a DUI is not a minor traffic offense), or ever entered into a diversion program instead of prosecution, including any convictions that have been expunged, deleted, or set aside and if so, the name of the jurisdiction, offense involved, date of offense, status of resolution, expected resolution date, and a narrative explanation;
p. Has been sued or prosecuted for an act or omission relating to the applicant’s practice as a psychologist, the applicant’s work under a certificate or license in another profession, or the applicant’s work as a member of a profession in which the applicant was not certified or licensed and if so, the name of the jurisdiction, allegation involved, and date;
q. Has ever been involuntarily terminated or resigned instead of termination from any psychological or behavioral health position or related employment and if so, the name of the employer involved and date;
r. Currently uses alcohol or another drug that in any way impairs or limits the applicant’s ability to practice psychology safely and competently; and
s. Has a medical, physical, or psychological condition that may impair or limit the applicant’s ability to practice psychology safely and competently;
5. Information about the applicant’s education and training:
a. Name and address of each university or college from which the applicant graduated, dates attended, date of graduation, degree received, name of department, and major subject area of study;
b. Name and department of the applicant’s major advisor;
c. Title of the applicant’s dissertation or Psy.D. project for the doctoral degree;
d. Official title of the applicant’s doctoral degree program or predoctoral specialty area;
e. Whether the doctoral degree program that the applicant attended was accredited by the American Psychological Association at the time of graduation;
f. Whether the applicant’s internship training program was an American Psychological Association- accredited program or a member of the Association of Psychology and Postdoctoral Internship Centers;
g. Location of each internship training program in which the applicant participated and each supervisor’s name and contact information; and
h. Documentation demonstrating that the applicant satisfied the core program requirements in A.R.S. § 32-2071(A)(4) and R4-26-202;
6. Areas of professional competence;
7. Intended area of professional practice in psychology;
8. Name, position, and address of at least two individuals to serve as references who:
a. Are psychologists licensed or certified to practice psychology in a United States or Canadian regulatory jurisdiction and who are not members of the Arizona Board of Psychologist Examiners;
b. Are familiar with the applicant’s work experience in the field of psychology or in a postdoctoral program within the three years immediately before the date of application. If more than three years have elapsed since the applicant last engaged in professional activities in the field of psychology or in a postdoctoral program, the references may pertain to the most recent three-year period in which the applicant engaged in professional activities in the field of psychology or in a postdoctoral program; and
9. History of employment for the past 10 years in the field of psychology including, for each position held, the:
d. Name and address of supervisor, and
e. Type of employment; and
10. Information demonstrating that the applicant satisfied the core program requirements in A.R.S. § 32-2071(A)(4) and R4-26-202;
11. An attestation by the applicant, that the information on the application is about the applicant, is true and correct, and is not being submitted fraudulently;
B. Additionally, an applicant shall submit:
1. An original, un-retouched, passport-quality photograph of the applicant that is no larger than 1.5 X 2 inches and taken no more than 60 days before the date of application;
2. The results of a self-query from the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank;
3. As required under A.R.S. § 41-1080(A), the specified documentation of citizenship or alien status indicating the applicant’s presence in the U.S. is authorized under federal law;
4. The Board’s Mandatory Confidential Information form;
5. The fee required under R4-26-108; and
6. Any other information authorized by statute.
C. In addition to the requirements in subsections (A) and (B), an applicant shall arrange to have the following directly submitted to the Board:
1. An official transcript from each university or college from which the applicant attended a graduate program or received a graduate degree that contains the date the degree was conferred;
2. An official document from the degree-granting institution indicating that the applicant completed a residency that satisfies the requirements of A.R.S. § 32-2071 (K);
3. For an applicant applying supervised preinternship hours toward licensure, an attestation submitted by the doctoral program training director, faculty supervisor, or other official of the doctoral-granting institution who is knowledgeable of the applicant’s preinternship experience verifying that the applicant’s preinternship experience meets the requirements of A.R.S. § 32-2071(D).
4. An attestation from the applicant’s supervisor, if available, or a psychologist knowledgeable of the applicant’s internship training program, verifying that the applicant’s internship training program meets the requirements in A.R.S. § 32-2071 (F). If the supervisor or knowledgeable psychologist is not available, the Board shall accept primary source verification received from the Association of State and Provincial Psychology Boards. In this subsection, “not available” means the supervisor or knowledgeable psychologist is deceased or all reasonable efforts to locate the supervisor or knowledgeable psychologist were unsuccessful;
5. For an applicant applying supervised postdoctoral experience toward licensure, an attestation from the applicant’s postdoctoral supervisor, if available, or a psychologist knowledgeable of the applicant’s postdoctoral experience verifying that the applicant’s postdoctoral experience meets the requirements in A.R.S. § 32-2071 (G). If the supervisor or knowledgeable psychologist is not available, the Board shall accept primary source verification received from the Association of State and Provincial Psychology Boards. In this subsection, “not available” means the supervisor or knowledgeable psychologist is deceased or all reasonable efforts to locate the supervisor or knowledgeable psychologist were unsuccessful;
6. Verification of all other psychology licenses or certificates ever held in any regulatory jurisdiction; and
7. An official notification of the applicant’s score on the national examination. An applicant who passed the national examination in accordance with the standard established at A.R.S. § 32-2072(A), shall have the examination score sent directly to the Board by the Association of State and Provincial Psychology Boards or by the regulatory jurisdiction in which the applicant originally passed the examination.