new jersey office of the attorney general division of .2018-02-15 · new jersey office of the...

New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

State Board of Psychological Examiners124 Halsey Street, 6th Floor, P.O. Box 45017

Newark, New Jersey 07101(973) 504-6470

Dear Applicant:

Recent legislation required the Division of Consumer Affairs to conduct Criminal History Record Background Checks of all Health Care Professionals prior to the issuance of a license or permit to practice in a health care profession (N.J.S.A. 45:1-25 et seq.). In order for the Division to conduct a Criminal History Record Background Check, you must complete the enclosed Certification and Authorization form and return it to the Board or Committee at the mailing address above.

Upon receipt of the completed Certification and Authorization form, the Board or Committee will forward to you information you will need to have your fingerprints recorded. The recording of your fingerprints is necessary to conduct the Criminal History Record Background Check.

Please note that you will be required to pay a $58.69 fee for this service at the time you schedule your appointment. Anticipate a minimal wait of four to five weeks before your permit is approved or a license is issued.

Sincerely,

State Board of Psychological Examiners

J. Michael Walker Executive Director

New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

State Board of Psychological Examiners124 Halsey Street, 6th Floor, P.O. Box 45017

Newark, New Jersey 07101(973) 504-6470

Application for Licensure as a Practicing Psychologist

Date:____________________________

Anonrefundableapplicationfilingfeeof$125,intheformofacheckormoneyordermadeouttotheStateofNewJersey,mustbesubmittedwiththisapplication.(Applicantsshouldunderstandthatiftheapplicationfilingfeeispaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufficientfunds,thenextstepinthelicensureorcertificationprocesswillbedelayeduntilthefeeispaid.)

TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants,without theirconsent.However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponsetootherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddressofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureofyourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleasedtothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.InformationthatyouprovideonthisapplicationmaybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct(OPRA).

Please print clearly. You must answer all of the questions on this application.

Personal Information Dateofbirth:_________________________ MonthDayYear

Dr. Mr.1. Name Mrs.________________________________________________________________ (_______________________) Ms. Lastname Firstname Middleinitial Maidenname

2. Address

Home:______________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

_____________________________________ ___________________________________ Telephonenumber(includeareacode) E-mailaddress

Business/Practiceaddress:______________________________________________________________________________ Nameofcompany Telephonenumber(includeareacode)

____________________________________________________________________________________________ Street City State ZIPcode County

Mailing: ____________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

Attachaclear,full-facepassport-stylephotograph(2x2)ofyourheadandshoulders,takenwithinthepastsixmonths.A photo is requiredwith eachapplication.

Donotuse staples toattach thephoto.

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3. SocialSecurityNumber YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosomayresultindenial/nonrenewalof licensureorcertification.

*SocialSecurityNumber: __________ -____________ -___________

*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupportEnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theCommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theCommitteeisalsoobligatedtoprovideyourSocialSecuritynumberto:

a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;

b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and

c. theNational PractitionerDataBank and theH.I.P.DataBank,when reporting adverse actions relating to health care professionals.

4. Citizenship/ImmigrationStatus

FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcertificatestoU.S.citizensorqualifiedaliens. Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofficeofU.S. CitizenshipandImmigrationServices(USCIS).

U.S.citizen AlienlawfullyadmittedforpermanentresidenceinU.S. Otherimmigrationstatus

Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe USCISat:1-800-375-5283.

5. ChildSupport

Pleasecertify,underpenaltyofperjury,thefollowing:

a. Doyoucurrentlyhaveachild-supportobligation? Yes No

(1)IfYes,areyouinarrearsinpaymentofsaidobligation? Yes No

(2)IfYes,doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No

b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No

c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No

d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No

InaccordancewithN.J.S.A.2A:17-56.44d,ananswerofYestoanyofthequestionsa(1)throughdmayresult inadenialoflicensureorcertification.Furthermore,anyfalsecertificationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediaterevocationorsuspensionoflicensureorcertification.

___________________________________ ___________________________________ ________________________ Applicantsname(pleaseprint) Applicantssignature Date

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6. MedicalConditionsQuestions Questionsathroughfpertaintomedicalconditionsanduseofchemicalsubstances.Pleasereadthedefinitionscarefully.Your

responseswillbetreatedconfidentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthoseportionsofthefollowingquestionswhichinquireastotheillegaluseofcontrolleddangeroussubstancesoractivityifyouhavereasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayasserttheFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.IfyouchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplication.YourapplicationforlicensureorcertificationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefusedtoansweronthebasisoftheFifthAmendment,providedthattheAttorneyGeneralfirstgrantsyouimmunityaffordedbystatutorylaw.(N.J.S.A.45:1-20.)

Ability to practice as a psychologististobeconstruedtoincludeallofthefollowing:

a. Thecognitivecapacitytoexercisethereasonablejudgmentsofapracticingpsychologist,andtolearnandkeepabreastofpro-fessionaldevelopments;and

b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtoclientsandotherinterestedparties,withorwithouttheuseofaidsordevices,suchasvoiceamplifiers;and

c. Thephysicalcapabilitytoperformthedutiesofapracticingpsychologist,withorwithouttheuseofaidsordevices,suchascorrectivelensesorhearingaids.

Medical Conditionincludesphysiological,mentalorpsychologicalconditionsordisorders,suchas,butnotlimitedtoorthopedic,visual,speechandhearingimpairments,cerebralpalsy,epilepsy,musculardystrophy,multiplesclerosis,cancer,heartdisease,diabetes,mentalretardation,emotionalormentalillness,specificlearningdisabilities,H.I.V.disease,tuberculosis,drugaddictionandalcoholism.

Chemical substanceistobeconstruedtoincludealcohol,drugsormedications,includingthosetakenpursuanttoavalidpre-scriptionforlegitimatemedicalpurposesandinaccordancewiththeprescribersdirection,aswellasthoseusedillegally.

Currentlydoesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactononesfunctioningasalicensee,orwithintheprevioustwoyears.

Illegal use of controlled dangerous substance means the use of a controlled dangerous substance obtained illegally (e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.

a. Doyouhaveamedicalconditionwhichinanywayimpairsorlimitsyourabilitytopracticeyourprofessionwithreasonableskillandsafety? Yes No

b. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseyoureceiveongoingtreat-ment(withorwithoutmedications)orparticipateinamonitoringprogram**?

Yes No Notapplicablec. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseofthefieldofpractice,

thesettingormannerinwhichyouhavechosentopractice?