APPLICATION FOR CERTIFICATE OF REGISTRATION AUTHORIZING SUPERVISED PRACTICE (Section 12, Regulation 74/15) Psychologist

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1 T H E C O L L E G E O F P S Y C H O L O G I S T S O F O N T I O L'O R D R E D E S P S Y C H O L O G U E S D E L ' O N T I O 110 Eglinton Avenue West, Suite 500, Toronto, Ontario M4R 1A3 Tel (416) Fax (416) cpo@cpo.on.ca * Website: APPLICATION FOR CERTIFICATE OF REGISTRATION AUTHORIZING SUPERVISED PRACTICE (Section 12, Regulation 74/15) Psychologist Applicants are advised to read through the following materials that may be found at in the Applicants section: Registration Guidelines: Psychologist Supervised Practice Supervisor s Agreement forms, Supervisor s Work Appraisal forms Supervision Resource Manual Your completed application form can be mailed or dropped off in-person to the College. The College will not accept faxed or ed application forms. The application fee of $230 CAD is payable to the College of Psychologists of Ontario by either cheque or money order, and must be included with the application form. The College will not accept payment of the application fee by credit card. July 2015

2 TABLE OF CONTENTS A B C1 C2 D E PERSONAL IDENTIFICATION.3 PREVIOUS CERTIFICATION STATUS..4 EDUCATIONAL PREPARATION.5 LANGUAGE FLUENCY.6 EXAMINATION ACCOMMODATION..7 COURSEWORK RECORDS.9 Biological Bases of Behaviour 10 Cognitive Affective Bases of Behaviour.11 Social Bases of Behaviour Psychology of the Individual.13 Ethics and Standards 14 Assessment and Evaluation.15 Intervention and Consultation.. 16 Research.17 History and Systems.18 F G H I J K L M AUTHORIZED SUPERVISED PRACTICE 20 PRACTICA AND INTERNSHIPS 21 PROFESSIONAL EXPERIENCE 22 THE CONTROLLED ACT OF COMMUNICATING A DIAGNOSIS DECLARATION OF GOOD CHARACTER 27 DECLARATION OF COMPETENCE.28 AUTHORIZATIONS..29 APPLICATION EXPIRY 30 Psychologist PAGE 2

3 A PERSONAL IDENTIFICATION A1 Date of Application: A2 Surname: First Given Name: Middle Name(s): A3 Home Address: Telephone: Business Address: Telephone: Preferred Mailing Address: Home Work A4 If applicable, list other surname or given name under which you have previously been trained or employed: A5 Are you legally entitled to work in Canada Psychologist PAGE 3

4 B PREVIOUS CERTIFICATION STATUS B1 If you are or have been registered, certified or licensed by a legal or professional board in another province, state or country, or by the American Board of Professional Psychology, give full details below, including name of agency or board, date of original license or certificate, title, specifically if designated, and licence or certificate number. You are required to request the agency or board to confirm directly to the College your status. B2 Has any diploma, certificate or license, relating to the profession of psychology or another health profession, granted to you ever been suspended, revoked, or made subject to terms or conditions If, please append details on a separate sheet headed B2. B3 Have you ever had an application for registration, certification or licensing as a psychological services provider rejected If, please append details on a separate sheet headed B3 B4 Have you ever been convicted of professional misconduct, incompetence, or incapacity in Ontario in relation to another health profession, or in another jurisdiction in relation to the profession of psychology or another health profession If, please append details on a separate sheet headed B4. B5 Are you the subject of a current proceeding for professional misconduct, incompetence, or incapacity, in Ontario in relation to another health profession, or in another jurisdiction in relation to the profession of psychology or another health profession If, please append details on a separate sheet headed B5. B6 Have you ever taken the Examination for Professional Practice in Psychology (EPPP) administered by the ASPPB If, you are required to have your EPPP score sent directly to the College by contacting the Association of State and Provincial Psychology Boards (ASPPB) Score Transfer Service. Psychologist PAGE 4

5 C1 EDUCATIONAL PREPARATION C1-1 Colleges and Universities Degree Awarded (e.g. Ph.D.) Date of Award Major Subject Minor Subject You are required to arrange for an official transcript of the courses and grades for both undergraduate and graduate degrees to be sent by the universities directly to the College. C1-2 Official title of the DEPARTMENT in which you were enrolled for graduate degree(s): Masters: Doctorate: C1-3 Title of degree/program in psychology at the graduate level: Masters: Doctorate: C1-4 Is your doctoral degree from a program that is CPA accredited C1-5 Title of masters thesis (or program equivalent of thesis): Supervisor: Reference, if published: C1-6 Title of doctoral thesis (or program equivalent of thesis): Supervisor: Reference, if published: Psychologist PAGE 5

6 C2 LANGUAGE FLUENCY This section of the application form applies only to applicants whose psychology degree was obtained from outside of Canada; USA; the United Kingdom; the Republic of Ireland; Australia; New Zealand or France. Prior to completing this section of the application form please review the College s Language Fluency Policy which is found in Appendix F of the Registration Guidelines. Please select from one of the following options: My psychology degree was obtained from outside of Canada; USA; the United Kingdom; the Republic of Ireland; Australia; New Zealand or France. However, the language of instruction, supervision, and clinical practice were entirely in English or French. Along with my application to the College, I am providing verification* in the form of a signed letter sent directly from my university to the College that verifies that the language of instruction, supervision and clinical practice was entirely in English or French. My psychology degree was obtained from outside of Canada; USA; the United Kingdom; the Republic of Ireland; Australia; New Zealand or France. Along with my application to the College, I am providing a report*, directly from the language testing agency to the College, that I have achieved the minimum scores indicated on one of the standardized language fluency tests approved by the College. My psychology degree was obtained from outside of Canada; USA; the United Kingdom; the Republic of Ireland; Australia; New Zealand or France. Along with my application to the College, I am providing to the Registration Committee other compelling evidence of language fluency* (e.g. evidence of registration and practice in an English or French practice environment for a minimum of the equivalent of two years full-time). My psychology degree was obtained from outside of Canada; USA; the United Kingdom; the Republic of Ireland; Australia; New Zealand or France. I am requesting to be exempted from the requirement on the basis of my documented disability which affects my ability to meet the requirement by completing a standardized language fluency test. Along with my application I am providing documentation in support of this request*. *Documentation must be sent directly to the College. Options for submitting documentation are: 1) A hard-copy original document mailed to the College at: 110 Eglinton Avenue West, Suite 500, Toronto, ON, M6N 2P3, OR 2) a PDF version of the document ed to the College at registration@cpo.on.ca, OR 3) Document faxed to the College at (416) Attn: Registration Department. Psychologist PAGE 6

7 D EXAMINATION ACCOMMODATION In the section below, please indicate whether you have a documented impairment or disability which will require accommodation during the writing of the Examination for Professional Practice in Psychology (EPPP) or the Jurisprudence and Ethics Examination (JEE), or when taking the Oral Examination. NO, I do not have a documented impairment or disability which will require accommodation when taking examinations. YES, I do have a documented impairment or disability which will require accommodation when taking examinations. If you have indicated YES in the section above, you are required to submit documentation from your regulated health care professional in support of the specific accommodation(s) you are requesting. You may select from the available accommodations listed below; if your disability or impairment requires an accommodation that is not specified in the list below, please contact registration staff at the College of Psychologists. Standard Accommodations for the EPPP include: Extra Time: Additional 30 minutes of writing time Additional 1 hour of writing time Additional 2 hour of writing time Additional 4 hour of writing time Other EPPP Accommodations include: Separate room Reader and/or Person to enter answers (with separate room) Sign-Language Interpreter (with separate room) Service Animal (with separate room) Access to medication and/or glucose meter Access to food and/or beverage Standard Accommodations for the JEE include: Extra Time: Additional 30 minutes of writing time Other JEE Accommodations include: Large Print Examination Reader and/or Person to enter answers (with separate room) Sign-Language Interpreter (with separate room) Service Animal (with separate room) Access to medication and/or glucose meter Access to food and/or beverage Psychologist PAGE 7

8 For taking the Oral Examination: Please contact registration staff at the College of Psychologists to discuss your specific requirements for taking this examination. IMPORTANT NOTE: IN ALL CASES, DOCUMENTATION FROM YOUR REGULATED HEALTH CARE PROFESSIONAL MUST BE SUBMITTED TO THE COLLEGE WELL IN ADVANCE OF AN EXAMINATION ADMINISTRATION IN ORDER TO ALLOW SUFFICIENT TIME FOR YOUR REQUEST TO BE REVIEWED AND FOR ACCOMMODATIONS TO BE ARRANGED. DOCUMENTATION FROM YOUR REGULATED HEALTH CARE PROFESSIONAL MUST SPECIFICALLY SUPPORT THE ACCOMMODATION(S) BEING REQUESTED. Psychologist PAGE 8

9 E COURSEWORK RECORDS In order to assess an applicant s educational background and preparation (both foundational knowledge in psychology and knowledge and skills for professional practice in psychology), the College requires detailed descriptions of all coursework in psychology. On the pages marked E1 to E10, please enter the details requested. Please use your best judgement when assigning courses to the categories at the head of each page. Please make supplementary photocopies of those pages where you wish to list more than four courses. Psychologist PAGE 9

10 E1 FOUNDATIONAL KNOWLEDGE Biological Bases of Behaviour Includes such courses as: Physiological psychology, Comparative Psychology, Neuropsychology, Sensation & Perception, Psychopharmacology a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 10

11 E2 FOUNDATIONAL KNOWLEDGE Cognitive Affective Bases of Behaviour Includes such courses as: Learning, Thinking, Motivation, Emotion, Cognition a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 11

12 E3 FOUNDATIONAL KNOWLEDGE Social Bases of Behaviour Includes such courses as: Social Psychology, Group Processes, Organizations & Systems, Community Psychology, Environmental Psychology, Cultural Issues a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 12

13 E4 FOUNDATIONAL KNOWLEDGE Psychology of the Individual Includes such courses as: Personality Theory, Human Development, Abnormal Psychology, Psychopathology, Individual Differences a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 13

14 E5 PROFESSIONAL PRACTICE Ethics and Standards Includes such courses as: Seminars devoted to professional issues and relevant legislation, Professional Ethics a. Course Title Institution For office use only Course (as shown on Of credits: Of instruction: b. Course Title Institution Course (as shown on Of credits: Of instruction: c. Course Title Institution Course (as shown on Of credits: Of instruction: d. Course Title Institution Course (as shown on Psychologist PAGE 14

15 E6 PROFESSIONAL PRACTICE Assessment and Evaluation Includes such courses as: Psychological Assessment Techniques, Psychodiagnostic Assessment, Neuropsychological Assessment, Program Evaluation, Clinical Psychology, Personality Assessment a. Course Title Institution Course (as shown on Of credits: Of instruction: b. Course Title Institution For office use only A R Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 15

16 E7 PROFESSIONAL PRACTICE Intervention and Consultation Includes such courses as: Psychotherapy, Counselling, Behaviour Modification, Intervention Techniques, Career Counselling, Psychological Consulting a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Year Taken 19 Course (as shown on Of credits: Of instruction: Psychologist PAGE 16

17 E8 PROFESSIONAL PRACTICE Research Includes such courses as: Research Design, Experimental Procedures, Laboratory Methods, Statistics, Multi-variate Analysis, Test Construction and Validation a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 17

18 E9 PROFESSIONAL PRACTICE History and Systems Includes such courses as: History of Psychology, Historical Development of Professional Practice a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 18

19 E10 Other psychology courses not covered in previous categories a. Course Title Institution For office use only Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 19

20 F AUTHORIZED SUPERVISED PRACTICE In F1 and F2, indicate the employment which will be carried out while holding a Certificate of Registration Authorizing Supervised Practice. F1 Title or Position Organization or Institution Name Position Start Date: General services offered by organization or institution: Your duties: Type of client: Full Time Part Time If part time, state number of hours you work per week: Supervisor s name: Address: Title: F2 Title or Position Organization or Institution Name Position Start Date: General services offered by organization or institution: Your duties: Type of client: Full Time Part Time If part time, state number of hours you work per week: Supervisor s name: Address: Title: Psychologist PAGE 20

21 G PRACTICA AND INTERNSHIPS Beginning with the most recent, give a complete record of your practica and internships. G1 Dates from: Title or position: Organization or institution name: General services offered by organization or institution: to: Practicum Internship Your duties: Type of client: Full Time Part Time Total Supervisor s name: Address: Supervisor s professional affiliation (e.g. College of Psychologists of Ontario): G2 Dates from: Title or position: Organization or institution name: to: Practicum Internship General services offered by organization or institution: Your duties: Type of client: Full Time Part Time Total Supervisor s name: Address: Supervisor s professional affiliation (e.g. College of Psychologists of Ontario): Psychologist PAGE 21

22 H PROFESSIONAL EXPERIENCE Beginning with the most recent, give a complete record of your experience. H1 Dates from: to: Title or position: Organization or institution name: General services offered by organization or institution: Your duties: Type of client: Full Time Part Time Total Supervisor s name: Address: Supervisor s professional affiliation (e.g. College of Psychologists of Ontario): H2 Dates from: to: Title or position: Organization or institution name: General services offered by organization or institution: Your duties: Type of client: Full Time Part Time Total Supervisor s name: Address: Supervisor s professional affiliation (e.g. College of Psychologists of Ontario): Psychologist PAGE 22

23 I THE CONTROLLED ACT OF COMMUNICATING A DIAGNOSIS Chapter 18, Section 27.(2) of the Regulated Health Professions Act states: (2) A controlled act is any one of the following done with respect to an individual: 1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely upon the diagnosis. Section 4. of the Psychology Act, 1991, states: In the course of engaging in the practice of psychology, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to communicate a diagnosis identifying, as the cause of a person s symptoms, a neuropsychological disorder or a psychologically based psychotic, neurotic or personality disorder. In the practice of psychology, in order to formulate and communicate a diagnosis, a member must have the following knowledge, skills and training directly relevant to the area(s) of practice, and client groups indicated on the Declaration of Competence form in order to treat the client and evaluate the effectiveness of the treatment. Therefore, the ability to communicate a differential diagnosis must apply to every psychologist or psychological associate, with the exception of those practising exclusively within the area of industrial/organizational psychology. Following the section of the application form where you list your coursework you will find a section to list your formal training. To demonstrate that you have the required knowledge base, please indicate which of your graduate courses has covered the following four required knowledge areas: Psychopathology Personality theory / individual differences Psychological assessment Psychodiagnostics An undergraduate course, while it informs the subsequent study, is not the equivalent of, or a substitute for, a graduate psychology course. You require the equivalent of a graduate half course (of approximately 36 hours duration) in each of the four knowledge areas. Although the subject may not be included in the course title, or the subject may be covered in more than one course, please use the boxes below to demonstrate as fully as possible that you have the necessary amount of graduate coursework coverage. If three boxes are not sufficient to list the necessary courses in each subject, please copy the page. Psychologist PAGE 23

24 I1 Psychopathology Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Brief description of course contents related to psychopathology including client group(s): Brief description of course contents related to psychopathology including client group(s): Brief description of course contents related to psychopathology including client group(s): I2 Personality Theory / Individual Differences Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Brief description of course contents related to personality theory/individual differences including client group(s): Brief description of course contents related to personality theory/individual differences including client group(s): Brief description of course contents related to personality theory/individual differences including client group(s): Psychologist PAGE 24

25 I3 Psychological Assessment Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Brief description of course contents related to psychological assessment including client group(s): Brief description of course contents related to psychological assessment including client group(s): Brief description of course contents related to psychological assessment including client group(s): I4 Psychodiagnostics Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Course Title Course (as shown on Previously listed on page # Brief description of course contents related to psychodiagnostics including client group(s): Brief description of course contents related to psychodiagnostics including client group(s): Brief description of course contents related to psychodiagnostics including client group(s): Psychologist PAGE 25

26 Please indicate the formal training as described in Section G, in your graduate program that has provided you with the skills for formulating and communicating a diagnosis. This page is suitable for copying should you require more space to list practica or internships. I5 (Please indicate box number in this application where you initially described this training, e.g. G1) Dates from: Organization or institution name: to: Practicum Internship Describe the nature of the activities and supervision in this setting that contributed to the development of your skills for formulating and communicating a diagnosis: I6 (Please indicate box number in this application where you initially described this training, e.g. G1) Dates from: Organization or institution name: to: Practicum Internship Describe the nature of the activities and supervision in this setting that contributed to the development of your skills for formulating and communicating a diagnosis: Psychologist PAGE 26

27 J DECLARATION OF GOOD CHARACTER All applicants must answer the following questions. Their purpose is to enable the College to determine whether or not the applicant is of good character. A yes answer to any question or questions will not necessarily result in a refusal to register. Further details may, however, be requested from the applicant if any question is answered in the affirmative. The details supplied by the applicant will form part of the material to be reviewed before a decision on registration is made. J1 Have you ever been found to have committed professional malpractice by a court or tribunal J2 Are you currently named as a defendant in any civil proceeding in which professional malpractice or negligence is alleged J3 Are you currently the subject of any inquiry, investigation or proceeding in respect of allegations of professional misconduct, incompetence, fitness to practise or incapacity J4 Have you ever been censured or reprimanded for sexual harassment or sexual misconduct J5 Have you ever been found guilty of academic dishonesty by a post-secondary educational institution J6 Have you ever been suspended or expelled from any post-secondary educational institution J7 Are you now abusing, dependant on, or being treated for the abuse or dependence on alcohol or a drug J8 Have you ever abused, been dependant on, or been treated for the abuse or dependence on alcohol or a drug J9 Have you ever been denied or had any license, certificate, registration or permit revoked due to lack of good character J10 Have you ever been suspended, disqualified, censured, or disciplined as a member of any professional organization J11 Has there ever been a finding of contempt of court made against you, or have you ever been found to have contravened or failed to comply with any order of any Court J12 Have you ever been found guilty of fraud or been found to have committed fraud J13 Have you ever been found guilty of a criminal offence for which a pardon has not been granted or of an offence relevant to the practice of psychology, either within a Canadian jurisdiction or elsewhere J14 Have you ever been dismissed from or asked to resign from any employment due to negligence, professional misconduct or academic dishonesty J15 Is there any event, circumstance, condition or matter not disclosed in your replies to the preceding questions touching upon your conduct, character or fitness to practise that might be an impediment to your registration as a psychologist Psychologist PAGE 27

28 K DECLARATION OF COMPETENCE Below, please indicate your area(s) of competence in the practice of psychology, and in which you will, through knowledge and formal training, be prepared to demonstrate competence prior to the award of a certificate of registration authorizing autonomous practice. You must be engaged in the identified practice area(s), activities and client groups during supervised practice. Assessment/Evaluation and Intervention/Consultation must be selected for each area chosen. Activities and Services Assessment / Evaluation Intervention/ Consultation Research Teaching Clinical Psychology Counselling Psychology School Psychology Area(s) Forensic/Correctional Psychology Clinical Neuropsychology Health Psychology Rehabilitation Psychology Industrial/Organizational Psychology Client group(s): Children Adults Seniors Adolescents Couples Organizations Families Name (please print): Date: Signature: Psychologist PAGE 28

29 L AUTHORIZATIONS L1 I authorize the College of Psychologists of Ontario to collect and maintain information from persons named in this application and from other persons or institutions as the College of Psychologists of Ontario in its discretion deems advisable in order to determine my eligibility for registration as a psychologist in the province of Ontario. I agree to save harmless all officers, directors, employees, servants and agents of the College of Psychologists of Ontario and those granting information regarding my application for registration at the request of the College of Psychologists of Ontario and hereby consent to the requesting and granting of any and all such information. I also authorize and consent to the release of any information obtained by the College of Psychologists of Ontario in the course of reviewing my application for registration at the request of any other professional body to whom I make application for registration, certification or licensing. L2 I certify that the statements made by me in this application are true, complete, and correct. I understand that a false statement may disqualify me from registration or be cause for revocation of any registration which may have been granted to me. L3 I have read the Registration Guidelines to assist my understanding of the requirements for registration as a psychologist. Signature: Date: If your degree is from an institution outside Canada or the United States, you must have it evaluated to determine if it is comparable in level to a recognized Canadian degree. You can arrange for this evaluation through one of the following credential evaluation services: Comparative Education Service (CES) ces.info@utoronto.ca Website: Tel.: (416) ext. 3 Fax: (416) Address: University of Toronto School of Continuing Studies 162 St. George Street Toronto ON M5S 2E9 World Education Services (WES) ontario@wes.org Website: Tel.: (416) Tel. (Toll free): Fax: (416) Address: 2 Carlton Street, Suite 1400 Toronto, Ontario M5B 1J3 If your transcripts are in a language other than English or French, you must obtain an official translation. The College will accept translations done by an official translation agency or official notarized translations prepared in the country of origin. Psychologist PAGE 29

30 M APPLICATION EXPIRY The College collects and uses the information in this application to assess whether you qualify to be issued with a certificate for supervised practice as a psychologist in Ontario. The College discloses information only as permitted by Section 36 of the Regulated Health Professions Act, or as required by law. An application fee, which is non-refundable, is required for receipt and processing of your application. It is your responsibility to check with the College to ensure that all necessary documentation has been received. Applications are not kept by the College indefinitely. An application for registration as a psychologist that has not resulted in the issuance of a certificate of registration or a statement of eligibility from the Registrar will expire 24 months after the date of the application (entered on Box A1 of this application form). The College will make reasonable efforts to contact the applicant prior to the date of application expiry. The College will scan and save electronically an applicant s application form and any supporting documents for 5 years from the date of application expiry. At the end of the 5 year period, the scanned information will be securely destroyed. Should the applicant re-apply for registration before the end of the 5 year period, he/she must submit a new application form and application fee to the College, and the College will endeavour to use whatever of the scanned original documentation that is appropriate. Psychologist PAGE 30