Psychology (Doctorate/Masters) Renewal Application

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1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Psychology (Doctorate/Masters) Renewal Application Board of Psychological Examiners Renewal Clerk (802) Current Expiration 01/31/2014 Renewal Period Covering 02/01/2014 through 01/31/2016 Renewal Application Fee $ [n Refundable Processing Fee] Checks Payable to: Vermont Secretary of State You Must Complete The Information Below: For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal application fee is non-refundable. If the completed renewal, along with all supporting documentation, is not received in the Office by the expiration date you will be required to pay a late renewal penalty. The penalty is $25.00 for renewals submitted less than 30 days late. Thereafter, the penalty increases by $5.00 for every additional month or fraction of a month, not to exceed $ Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country If your 911 address has changed, indicate your new address in the box to the right. Street/Apt # Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female

2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.

3 Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3

4 Section D: Continuing Education Requirement You are not required to send any supporting documentation with this form if you renew by the license expiration date. The Office of Professional Regulation reserves the right to verify information submitted by applicants for renewal through a random audit. You must retain all documentation for seven years after completion of the program/course. To assist you in documenting your continuing education, please download the Continuing Education Record from our web site at If you are renewing more than 30 days late, you must submit all CE documents with your completed renewal form. Board of Psychological Examiners Administrative Rule 8.1 Continuing Education Renewal Requirements At each renewal, each licensee must document attendance or participation in 60 hours of continuing education. (a) fewer than 6 of those hours must be specially devoted to professional psychologist ethics. (b) more than 30 hours may be dedicated to any one topic. (c) Self-help activities and programs or activities that are designed to increase income or office efficiency will not be counted toward the continuing education requirement. (d) license will be renewed until the licensee submits a verification of compliance with the continuing education requirements Board of Psychological Examiners Administrative Rule 8.4 Acceptable Continuing Educational Activities Continuing education may be obtained via: (a) large group and formal presentations; (b) small group activities; and (c) individual activities. Board of Psychological Examiners Administrative Rule 8.5 Large Group Activities and Formal Presentations (c) fewer than 24 hours of the 60 hours must be obtained from large group and formal presentation activities. Board of Psychological Examiners Administrative Rule 8.8 Individual Activities (f) minimum number of individual activities is required, but no more than 24 hours of the 60 hours may be obtained via individual activities. For this licensing renewal, because the continuing education requirements changed half way through the renewal cycle, the Board will allow for continuing education credits to have been obtained by either the current rules or the old rules. Effective with the 2/1/2014-1/31/2016 renewal cycle, all psychologists must adhere to the new rules. Continuing Education Requirement (Check the box that applies to your license.) My Psychology license was first issued in Vermont on or after 02/01/2012; therefore I do not have to complete continuing education for this renewal cycle (0 hours). My Psychology license was first issued in Vermont prior to 02/01/2012, and I have completed 60 hours of continuing education (including 6 hours in Ethics). I have NOT met the continuing education requirement (CE extensions may be granted in exceptional circumstances for good cause shown upon written request with a completed renewal form and fee submitted prior to the expiration date.) Name (print): License Number: 4

5 Section E: Expired License If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section F: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Signature Date (MM/DD/YYYY) Print Name: License # _ ---- Name (print): License Number: 5

6 Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2014 Renewal License #: ---- Name: 1. Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 6

7 43956 VERMONT DEPARTMENT OF HEALTH CENSUS OF PSYCHOLOGISTS 2014 This census is designed to assess the distribution of psychologists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 1 Vermont License Number (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) First Name Middle Name Last Name 1. Gender: Male Female 2. Are you Hispanic or Latino/a? Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Prefer not to answer 4. What is your highest psychology degree? Master's Degree (MA, MS, MED) Specialist Certificate (EdS, PsyS, SSP, CAGS) PhD PsyD EdD Other Birthdate (mm-dd-yyyy) Race? (check all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or Pacific Islander White Other Prefer not to answer 5. In what year did you complete your highest psychology degree? 6. Enter the two-letter code for the state where you completed your highest psychology degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. If you possess a doctoral degree in psychology: Did you complete a one year (full time) or two year (half time) psychology internship as part of that doctoral program? If yes, was it APA accredited? Was it CPA accredited? N/A Did you complete one year (full time) or two years (half time) of post-doctoral supervised training? N/A Did you complete a program of doctoral re-specialization? N/A Don't know Don't know Please continue on next page. Thank you

8 43956 VERMONT DEPARTMENT OF HEALTH CENSUS OF PSYCHOLOGISTS 2014 This census is designed to assess the distribution of psychologists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 2 Vermont License Number (Please re-enter your license number for scanning purposes) 8. In what year did you obtain your first psychology license? 9. Which of the following psychology licensure titles do you maintain? (Select all that apply) Psychologist Psychological Examiner Psychologist / Health Service Provider Psychological Associate School Psychologist Psychological Technician Psychological Assistant 10. Please describe your current employment status: (check all that apply) * Actively working in a position that requires a psychology license Actively working in a position that does not require a psychology license Actively working in a field other than psychology t currently working Retired 11. Do you provide direct patient care in Vermont as a psychologist? IF you are not providing direct patient care IN VERMONT as a psychologist, PLEASE STOP HERE AND RETURN SURVEY 12. Which best describes your current employment arrangement at your primary Vermont practice location regarding direct client/patient care? Self employed Salaried employment Hourly employment Temporary Employment Other (please specify): 13. What are your plans for the next 12 months regarding direct client/patient care in Vermont? Increase hours in patient care Decrease hours in patient care Seek a non-clinical job Retire Continue as you are Unknown Please continue on next page. Thank you

9 43956 VERMONT DEPARTMENT OF HEALTH CENSUS OF PSYCHOLOGISTS 2014 This census is designed to assess the distribution of psychologists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 3 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. SITE ONE (principal site) - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): This site is a (please choose ONE): Psychiatric Hospital Hospital / Medical Center Mental Health Clinic Substance Abuse Treatment Facility Health Clinic / Outpatient Facility Child Welfare Facility College/University Counseling/Health Ctr Correctional Facility Criminal Justice Facility Hospice Independent Group Practice Independent Solo Practice Long-term care facility Organization/Business Setting Rehabilitation Residential setting School based mental health Veterans facility During how many weeks did you work at this site as a psychologist in the past year: (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) Child & Adolescent Psychology Clinical Health Psychology Clinical Neuropsychology Clinical Psychology Cognitive Behavioral Psychology Counseling Psychology Couple & Family Psychology Forensic Psychology Group Psychology Organizational & Business Counseling Police & Public Safety Psychology Professional Geropsychology Psychoanalytic Psychology Rehabilitation Psychology School Psychology Please indicate the average number of hours of direct patient care (excluding emergency call) spent per working week in the past year at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you

10 43956 VERMONT DEPARTMENT OF HEALTH CENSUS OF PSYCHOLOGISTS 2014 This census is designed to assess the distribution of psychologists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 4 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Child & Adolescent Psychology Clinical Health Psychology Clinical Neuropsychology Clinical Psychology Cognitive Behavioral Psychology Counseling Psychology Couple & Family Psychology Forensic Psychology Group Psychology Organizational & Business Counseling Police & Public Safety Psychology Professional Geropsychology Psychoanalytic Psychology Rehabilitation Psychology School Psychology Please indicate the average number of hours of direct patient care (excluding emergency call) spent per working week in the past year at this site in your secondary specialty area mentioned above: Hours per week What other type(s) of licensed health or mental health professionals work at this location (if any)? Dentists Licensed Professional Counselors Marriage and Family Therapists Nurse Practitioners Nurses Physician Assistants Psychiatrists Physicians other than Psychiatrists Social Workers Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Clinical Supervision Community & Prevention Forensics, consulting, etc n clinical consultation Administration / Management Please answer the following questions for your work at this site: Teaching/Education/Research I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: * Other activities If you have a second practice site, continue on the next page. If you only have one practice site, stop here, but please return all 6 pages. Please return all sheets (6 pages) even if some are blank. Thank you

11 43956 VERMONT DEPARTMENT OF HEALTH CENSUS OF PSYCHOLOGISTS 2014 This census is designed to assess the distribution of psychologists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 5 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. SITE TWO (if any) - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): This site is a (please choose ONE): Psychiatric Hospital Hospital / Medical Center Mental Health Clinic Substance Abuse Treatment Facility Health Clinic / Outpatient Facility Child Welfare Facility College/University Counseling/Health Ctr Correctional Facility Criminal Justice Facility Hospice Independent Group Practice Independent Solo Practice Long-term care facility Organization/Business Setting Rehabilitation Residential setting School based mental health Veterans facility During how many weeks did you work at this site as a psychologist in the past year: (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) Child & Adolescent Psychology Clinical Health Psychology Clinical Neuropsychology Clinical Psychology Cognitive Behavioral Psychology Counseling Psychology Couple & Family Psychology Forensic Psychology Group Psychology Organizational & Business Counseling Police & Public Safety Psychology Professional Geropsychology Psychoanalytic Psychology Rehabilitation Psychology School Psychology Please indicate the average number of hours of direct patient care (excluding emergency call) spent per working week in the past year at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you

12 43956 VERMONT DEPARTMENT OF HEALTH CENSUS OF PSYCHOLOGISTS 2014 This census is designed to assess the distribution of psychologists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 6 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Child & Adolescent Psychology Clinical Health Psychology Clinical Neuropsychology Clinical Psychology Cognitive Behavioral Psychology Counseling Psychology Couple & Family Psychology Forensic Psychology Group Psychology Organizational & Business Counseling Police & Public Safety Psychology Professional Geropsychology Psychoanalytic Psychology Rehabilitation Psychology School Psychology Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Clinical Supervision Community & Prevention Forensics, consulting, etc n clinical consultation Administration / Management Teaching/Education/Research Other activities Please indicate the average number of hours of direct patient care (excluding emergency call) spent per working week in the past year at this site in your secondary specialty area mentioned above: Hours per week Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, specialty, weeks and hours: more Please return all sheets (6 pages) even if some are blank. Thank you

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