TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF PSYCHOLOGY

Forms

Titles of Regulations: 18VAC125-20. Regulations Governing the Practice of Psychology.

18VAC125-30. Regulations Governing the Certification of Sex Offender Treatment Providers.

Agency Contact: Erin Barrett, Director of Legislative and Regulatory Affairs, Board of Psychology, 9960 Mayland Drive, Suite 300, Henrico, VA 23233, telephone (804) 750-3912, or email erin.barrett@dhp.virginia.gov.

FORMS (18VAC125-20)

Application Instructions For Clinical Psychology (LCP), School Psychology, or Applied Psychology Licensure by Examination (rev. 4/2018)

Endorsement Application Instructions for Licensure as a Clinical, School, or Applied Psychologist (rev. 12/2018)

Application Instructions for Licensure as a School Psychologist-Limited (rev. 5/2018)

Employment Verification (rev. 5/2018)

Registration of Residency in Clinical or School Psychology (Post-Graduate Degree Supervised Experience) (rev. 5/2018)

Psychologist Application for Reinstatement of a Lapsed License (rev. 5/2018)

School Psychologist-Limited Application for Reinstatement of a Lapsed License (rev. 5/2018)

Psychologist/CSOTP Application for Reinstatement Following Disciplinary Action (rev. 5/2018)

Verification of Post-Degree Supervision (rev. 5/2018)

Internship Verification (rev. 5/2018)

Licensure/Certification Verification (rev. 5/2018)

Areas of Graduate Study (rev. 5/2018)

Continuing Education Summary Form (rev. 12/11)

Verification of Pre-Doctoral Supervised Practicum Hours (eff. 5/2018)

Verification of Post-Licensure Active Practice (rev. 8/2018)

Licensure Verification of Out-of-State Supervisor (rev. 5/2018)

Form for Reporting Psychology Grand Rounds Attendance (rev. 10/2011)

Continuing Education/Course Approval Request (rev. 4/2018)

Request for Board Approval of Evaluator (rev. 10/2017)

Request for Board Approval of Practice Supervisor (rev. 10/2017)

Request for Board Approval of Therapist (rev. 10/2017)

Psychology Name/Address Change Form (rev. 3/2016)

Request for Verification of Virginia Psychology License (rev. 7/2017)

Request for Change in Status of Virginia Clinical, School or Applied Psychologist License and School Psychologist Limited License (Current Active to Current Inactive) (rev. 5/2020)

Request for Change in Status of Virginia Psychology License (Current Inactive to Current Active) (rev. 5/2020)

Request for Change in Status of Virginia Psychology License (Current Inactive to Current Active at Annual Renewal Time) (rev. 5/2020)

Initial Licensure by Examination for Clinical Psychology (rev. 10/2024)

Licensure by Endorsement for Clinical Psychology (rev. 10/2024)

Initial Licensure by Examination for School Psychology (rev. 10/2024)

Licensure by Endorsement for School Psychology (rev. 10/2024)

Initial Licensure by Examination for Applied Psychology (rev. 10/2024)

Licensure by Endorsement for Applied Psychology (rev. 10/2024)

Initial Licensure for School Psychologist-Limited (rev. 10/2024)

Initial Licensure by Examination for Psychological Practitioner (rev. 9/2025)

Initial Licensure by Examination for Autonomous Psychological Practitioner (rev. 9/2025)

Verification of Post-Degree Supervision for Psychological Practitioner Autonomous Practice (rev. 9/2025)

Change of Status Request Active to Inactive (rev. 8/2024)

Change of Status Request Inactive to Active at Renewal (rev. 8/2024)

Change of Status Request Inactive to Active (rev. 8/2024)

Reinstatement Application for Clinical, School, Applied, and Psychological Practitioner (rev. 10/2025)

Reinstatement Following Disciplinary Action for Clinical, School, and Applied (rev. 10/2024)

Reinstatement for School Psychology-Limited (rev. 10/2024)

School Psychologist-Limited Employment Verification (rev. 8/2024)

Initial Registration of Residency for Clinical Psychology (rev. 10/2024)

Add/Change Residency for Clinical Psychology (rev. 10/2024)

Termination of Supervision Form - Clinical Psychology (rev. 8/2024)

Resident in Clinical Psychology Supervisor Contract (rev. 9/2023)

Initial Registration of Residency for School Psychology (rev. 10/2024)

Add/Change Residency for School Psychology (rev. 10/2024)

Termination of Supervision - Resident in School Psychology (rev. 8/2024)

Resident in School Psychology Supervisor Contract (rev. 8/2023)

Verification of Post-Degree Supervision for Clinical Psychology (rev. 8/2024)

Internship Equivalency Form (rev. 3/2025)

Verification of Active Practice - Clinical Psychology (rev. 8/2024)

Verification of Internship - Clinical Psychology (rev. 8/2024)

Verification of Pre-Doctoral Supervised Practicum Hours - Clinical Psychology (rev. 8/2024)

Verification of Post-Degree Supervision for School Psychology (rev. 8/2024)

Verification of Internship - School Psychology (rev. 8/2024)

Verification of Post-Licensure Active Practice - School Psychology (rev. 8/2024)

Areas of Graduate Study - Verification of Required Coursework for Clinical Psychologists (rev. 8/2024)

Areas of Graduate Study - Verification of Required Coursework for School Psychologists (rev. 8/2023)

Areas of Graduate Study - Verification of Required Coursework for Applied Psychologists (rev. 8/2024)

Areas of Graduate Study - Verification of Required Coursework for Psychological Practitioners (rev. 9/2025)

Continuing Education Summary Form (rev. 11/2025)

Request for Virginia Licensure Verification (rev. 8/2024)

Supervisor Out-of-State Verification Form (rev. 8/2024)

Verification of Active Practice for Applied Psychologists (rev. 8/2024)

Request for Board Approval of Practice Supervisor (rev. 9/2024)

Authorization to Disclose for Practice Supervisor (rev. 11/2025)

Practice Supervisor Report (rev. 9/2024)

Initial Therapy Report for Compliance (rev. 9/2024)

Therapy Quarterly Report for Compliance (rev. 9/2024)

Licensee Self Report (rev. 9/2024)

Request for Board Approval of Therapist (rev. 9/2024)

Group Attendance Log (rev. 9/2024)

Prescription Report (rev. 9/2024)

Initial Contact Form for Compliance (rev. 9/2024)

Employer Notification of Board Order (rev. 9/2024)

Name or Address Change Form (rev. 8/2024)

Continuing Education or Course Approval Request for Compliance Monitoring (rev. 9/2024)

Request for Board Approval of Evaluator (rev. 9/2024)

FORMS (18VAC125-30)

Application Instructions for Certification as a Sex Offender Treatment Provider (rev. 12/2020)

Applicant Out-of-State Licensure Verification (rev. 12/2020)

Verification of Post-Degree Supervision (rev. 12/2020)

Verification of Training (rev. 12/2020)

Applicant Out-of-State Supervisor Licensure Verification (rev. 12/2020)

Application Instructions for Initial Registration of Supervision for Sex Offender Treatment Providers (rev. 12/2020)

Application Instructions for Add/Change Registration of Supervision for Sex Offender Treatment Providers (rev. 12/2020)

Reinstatement Instructions for Certification of Sex Offender Treatment Providers (rev. 12/2020)

Application for Certification as a Sex Offender Treatment Provider (rev. 10/2024)

Verification of Post-Degree Supervision (rev. 8/2024)

Verification of Training Certified Sex Offender Treatment Provider (rev. 08/2024)

Applicant Out-of-State Verification Form (rev. 8/2024)

Supervisor Out-of-State Verification Form (rev. 8/2024)

Application for Initial Residency as Sex Offender Treatment Provider Trainee (rev. 10/2024)

Request for Termination of Supervision (rev. 8/2024)

Sex Offender Treatment Provider Add/Change Residency (rev. 10/2024)

Reinstatement Application for Sex Offender Treatment Providers (rev. 10/2024)

Reinstatement Application for Sex Offender Treatment Providers Following Disciplinary Action (rev. 10/2024)

Sex Offender Treatment Trainee Supervisor Contract (rev. 3/2023)

Continuing Education Summary Form (rev. 11/2025)

Employer Notification of Board Order (rev. 9/2024)

Name or Address Change Form (rev. 8/2024)

Continuing Education or Course Approval Request for Compliance Monitoring (rev. 9/2024)

Request for Board Approval of Evaluator (rev. 9/2024)