Free 50256.FH11 - Indiana

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APPLICATION FOR APPROVAL OF PROFESSIONAL SUPERVISION FOR CONTINUING EDUCATION CREDIT FOR PSYCHOLOGISTS
State Form 50256 (R2 / 9-07)

RETURN THIS APPLICATION TO: INDIANA STATE PSYCHOLOGY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

* Disclosure of your Social Security number is MANDATORY according to IC 4-1-8-1 and this application cannot be processed without it. FOR AGENCY USE ONLY
Date reviewed (month, day, year) Decision: Initials

DO NOT WRITE ABOVE THIS LINE THIS FORM IS TO BE USED BY LICENSED PSYCHOLOGISTS WHO ARE APPLYING FOR APPROVAL OF PROFESSIONAL SUPERVISION FOR CATEGORY II CONTINUING EDUCATION CREDIT. ONLY INDIVIDUAL FACE-TO-FACE SUPERVISION MAY BE CLAIMED FOR CREDIT. A MAXIMUM OF TEN HOURS OF CREDIT MAY BE EARNED FOR PROFESSIONAL SUPERVISION IN EACH TWO YEAR LICENSE PERIOD. ONLY PERSONS RECEIVING SUPERVISION MAY EARN CREDITS.
Name of applicant Address (number and street, city, state, and ZIP code) Telephone number (daytime) E-mail address Social Security number * INFORMATION ABOUT THE APPLICANT License number

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INFORMATION ABOUT THE SUPERVISOR

Name of supervisor

Is supervisor licensed to practice psychology in Indiana? If no, please describe the credentials of your supervisor:

Yes

No

Location of supervision: Name of facility

Address (number and street, city, state, and ZIP code)

Nature of supervision (what functions did you perform under supervision)?

Beginning and ending dates of supervision (month, day, year) Number of hours of supervision (individual face-to-face supervision only) Number of credit hours claimed

(Continued on the reverse side.)

APPLICATION AFFIRMATION
I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete, and correct. Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize and direct any person, firm, officer, corporation, association, organization, or institution to release to the Professional Licensing Agency, or the Indiana State Psychology Board, any files, documents, records, or other information pertaining to the named applicant requested by the Agency or the Board or any of their authorized representatives, in connection with processing this application for approval of professional supervision. I hereby release the aforementioned persons, firms, corporations, associations, organizations, and institutions from nay liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency or the Indiana State Psychology Board to disclose to the aforementioned organizations, persons, and institutions any information which is material to any application, and I hereby specifically release the Agency, and the Board, from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same. Signature of applicant Date signed (month, day, year)