Dear School Psychologist:

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1 125 W. Market Street Suite 300 Indianapolis, IN (866) or (317) Dear School Psychologist: Enclosed is information regarding the application process for an independent practice endorsement (IPE) in Indiana. You have two years to complete the application process. Please make copies of all materials being submitted with your IPE application for your record keeping. Enclosed: An application checklist Application for endorsement Form A Form B Form C Form D Please complete all forms listed above and submit with your application. The following are the requirements for obtaining your IPE. Additional information can be found at IC or on the IASP website at 1. You must be a licensed school psychologist in Indiana 2. You must be employed as a school psychologist at least 30 hours a week (Form B) 3. You must provide a copy of your transcript showing: a. At least 60 graduate semester hours or 90 quarter hour master s or specialist degree in school psychology b hours internship at least 600 hours must be in a school setting 4. You must provide documentation of 1200 hours (after graduation not including your internship) at least 600 which must be in a school setting of supervised experience by a physician, a psychologist, or a school psychologist with an IPE or NCSP (Form A) 5. You must provide documentation/certificate of 12 hours of training provided by an HSPP or a psychiatrist in the identification and referral of mental and behavioral disorders (this can be obtained by attending the DSM course offered by IASP in even numbered years) 6. You must provide documentation of 10 case studies or evaluations requiring the identification or referral of mental or behavioral disorders. (Form C) 7. You must provide documentation of 30 hours of supervision with a physician, a psychologist, or a school psychologist with an IPE or NCSP. These hours must be completed within 24 months but not less than 6 months and cannot include more than 1 hour per week 8. You must provide documentation of passing PRAXIS exam or NCSP All forms should be submitted together to the IASP office at the above address. If you have any questions regarding the application process or requirements, please contact Kim Williams via phone (866) or Once your application has been approved by IASP you will receive notification so you can apply online with the Indiana Department of Education to add the IPE to your state license.

2 APPLICATION FOR ENDORSEMENT FOR INDEPENDENT PRACTICE Checklist for Independent Practice Endorsement Application. Complete and return with your application. Name Address I am a licensed school psychologist in Indiana I am employed as a school psychologist at least 30 hours a week (Form B) Copy of transcript showing: o At least 60 graduate semester hours or 90 quarter hour master s or specialist degree in school psychology o 1200 hours internship at least 600 hours must be in a school setting Documentation of 1200 hours (after graduation not including your internship) at least 600 which must be in a school setting of supervised experience by a physician, a psychologist, or a school psychologist with an IPE or NCSP (Form A) Documentation/certificate of 12 hours of training provided by an HSPP or a psychiatrist in the identification and referral of mental and behavioral disorders (this can be obtained by attending the DSM course offered by IASP) Documentation of 10 case studies or evaluations requiring the identification or referral of mental or behavioral disorders. (Form C) Documentation of 30 hours of supervision with a physician, a psychologist, or a school psychologist with an IPE or NCSP. These hours must be completed within 24 months but not less than 6 months and cannot include more than 1 hour per week (Form D) Documentation of passing PRAXIS exam or NCSP IASP office use only Action Recommended: The applicant is recommended for the independent practice endorsement. The applicant did not meet application requirements. Application is incomplete. Needed: IPE # IPE Exp Date: Reviewed by: Name Date

3 APPLICATION FOR ENDORSEMENT AS AN INDEPENDENT PRACTICE SCHOOL PSYCHOLOGIST Return completed application materials to Indiana Association of School Psychologists 125 West Market Street, Suite 300 Indianapolis, IN Please type or print legibly. Telephone number: (317) , (866) Directions: Answer all questions. Return this application along with all items on the checklist to the address above. 1. Name of applicant [last, first, middle, (maiden)] 2. Address (number and street, city, state, ZIP code) 3. Home telephone number (include area code) Work telephone number (include area code) 4. address 5. Date of birth (month, day, year) 6. Indiana Professional Educator s License number (Please enclose a copy of your current license) 7. Nationally Certified School Psychologist number (Please enclose a copy of your current NCSP card or certificate, if applicable.) 8. Education: Please complete in order of highest degree first, followed by other degrees. Include graduate and undergraduate education. LOCATION DATES OF GRADUATE INSTITUTION (City, ATTENDANCE DEGREE TITLE/AREA State) (mm,yy) SEMESTER HRS *Please enclose transcript of graduate work. 9. Employment History. Please list places of employment for the past 10 years. NAME AND ADDRESS OF EMPLOYER TITLE HRS OF EMPLOYMENT PER WEEK DATES OF EMPLOYMENT (mm/yy) to (mm/yy) *Please provide written documentation from all employers verifying this information (see Form B)

4 10. Retirement Exemption: Name of last employer Date last employed Address of last employer (number and street, city, state, ZIP code) Name of most recent supervisor Telephone number Address of most recent supervisor (number and street, city, state, ZIP code). 11. Medical Exemption: Name of attending physician Address of attending physician (number and street, city, state, ZIP code) Date and nature of disability. Please send any records pertinent to your request for a medical exemption. Please answer the following questions. If you answer Yes to ANY of these questions explain fully, in a sworn affidavit, including all relevant details. Describe the event including location, date, and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of an endorsement. 12. Has disciplinary action ever been taken regarding any school psychology license, certificate, registration, or permit you hold or have held? Yes No 13. Have you ever been denied a license, certificate, registration, or permit to practice school psychology or any regulated health or school occupation in any state or country? Yes No 14. Are you now being, or have ever been treated for a drug abuse or alcohol problem? Yes No 15. Have you ever been convicted, pled guilty to, pled nolo contendre to: a. A violation of any federal, state, or local law relating to the use, manufacturing, distribution, or dispensing of controlled substances or illegal drugs? Yes No b. Any offense, misdemeanor, or felony in any state? (Except minor violations of traffic laws resulting in fines.) Yes No 16. Have you ever been denied staff membership or privileges in any hospital, health care facility, or education facility or had such privileges revoked, suspended, or subjected to any restrictions, probation, or other type of discipline or limitations? Yes No 17. Have you ever been admonished, censored, reprimanded, or requested to withdraw, resign, or retire from any hospital, health care facility, or educational facility in which you have trained, held staff membership or privileges, or acted as a consultant? Yes No 18. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes No Please answer the following questions in regard to your completion of the IPE requirements. (Please submit the appropriate documentation: transcript, Forms C and D.) 19. Have you successfully completed at least 1200 hours of school psychology experience after completion of graduate degree requirements (and not including the internship required for degree completion or licensing)? Yes No 20. Have you completed thirty (30) hours of supervision within 24 consecutive months but not less than six (6) months, with not more than one (1) hour of supervision per week? Yes No 21. Have you completed ten case studies and/or evaluations requiring the identification or referral of mental or behavioral disorders during the time of supervision? Yes No 22. Have you completed 12 hours of training in the identification and referral of mental and behavioral disorders provided by a health service professional in psychology (HSSP) or psychiatrist? Yes No

5 APPLICATION AFFIRMATION I hereby swear under penalty of perjury that the above information and statements are true, complete, and correct and that I will uphold the ethical standards as set forth by the National Association of School Psychologists. Signature of applicant Date (month, day, year) AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization, or institution to release to the Indiana Department of Education any files, documents, records, or other information, pertaining to the undersigned, requested by the Board or any of their authorized representatives in connection with processing my application for endorsement as an independent practice school psychologist. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, persons, and institutions from any liability with regard to such inspection or furnishing of such information. I further authorize the Indiana Department of Education or any of their authorized representatives to disclose to the aforementioned organizations, person, and institutions any information which is material to my application, and I hereby specifically release the Indiana Department of Education or its representatives from any and all liability in connection with such disclosures. A photocopy of this authorization has the same force and effect as the original. AFFIRMATION Signature of applicant Date (month, day, year)

6 FORM A VERIFICATION OF SUPERVISED EXPERIENCE Applicant instructions: Please complete the top section of this form, then forward it to your post-graduate supervisor. You are authorized to photocopy this form if necessary. Name of applicant [last, first, middle, (maiden)] Address (number and street, city, state, ZIP code) Telephone number (home) Date of birth (month, day, year) I hereby authorize to furnish the Indiana Department of Education and the Indiana Name of supervisor Association of School Psychologists with the information below. Signature of applicant Date (month, day, year) SUPERVISION INFORMATION Supervisor instructions: Complete the remainder of this form and return to applicant. Name of Supervisor (last, first, middle) Title Name of business/school Telephone number address NCSP # (if applicable) Business address IPE or HSPP # (if applicable) Professional Educator s License # Expiration date of Indiana license: APPLICANT EMPLOYMENT INFORMATION Applicant s job description during time of your supervision: Beginning and ending dates of IPE supervision: Has the applicant successfully completed at least 1200 hours of school psychology experience after completion of graduate degree requirements (and not including the internship required for degree completion or licensing) ) at least 600 which must be in a school setting of supervised experience by a physician, a psychologist, or a school psychologist with an IPE or NCSP)? Yes No Has the applicant completed thirty (30) hours of supervision within 24 consecutive months but not less than six (6) months, with not more than one (1) hour of supervision per week? Yes No Has the applicant completed ten case studies and/or evaluations requiring the identification or referral of mental or behavioral disorders during the time of supervision? Yes No Please provide a brief description of how the supervision was conducted. The above indicated supervision was performed by me pursuant to my order, control, and full professional and legal responsibility as a supervisor. I do hereby declare that the information contained herein is true and correct. Signature of supervisor Title Date (month, day, year)

7 FORM B VERIFICATION OF EMPLOYMENT / EXPERIENCE Applicant instructions: Please complete the top section of this form, then forward it to your employer. You are authorized to photocopy this form if necessary. Name of applicant [last, first, middle, (maiden)] Address (number and street, city, state, ZIP code) Telephone number (home) Date of birth (month, day, year) Name of Supervisor (last, first, middle) Title Name of business Business address (number and street, city, state, ZIP code) I hereby authorize to furnish the Indiana Department of Education and the Indiana (name of employer) Association of School Psychologists with the information below. Signature of applicant Date (month, day, year) Employer instructions: Complete the remainder of this form and return to applicant. Name of business / institution where employed Type of facility: Developmental Center Mental Health Center State Hospital Public/Private Hospital Public/Private School Rehabilitation Center Address (number and street, city, state, ZIP code) Telephone number Fax number Date employment began Date employment ended (if currently employed, please indicate) Position held Hours worked per week during the contract period The above indicated experience has been performed by the applicant pursuant to my order, control, and full professional and legal responsibilities as an employer. I do hereby declare that the information contained herein is true and correct. Signature of employer Title Date (month, day, year) Telephone number address

8 FORM C CASE STUDIES Provide documentation of 10 case studies or evaluations requiring the identification or referral of mental or behavioral disorders. Applicant Name Supervisor Name Site of Supervision Date Supervision Began Date Ended Student Initials Dates of Consultation Behavior/Mental Health Concern Applicant Signature Date Supervisor Signature Date

9 FORM D SUPERVISION LOG SUMMARY Only one hour per week. Must be within 24 months/not less than six months. Total hours should equal 30. Applicant Name Supervisor Name Site of Supervision Date Supervision Began Date Ended Record actual dates of one-hour face-to-face supervision below: Applicant Signature Date Supervisor Signature Date

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