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9960 Mayland Drive, Suite 300
Henrico, VA 23233-1463
www.dhp.virginia.gov/psychology/
Email: [email protected]
(804) 367-4697 (Tel)
(804) 767-3626 (Fax)
APPLICATION FOR TEMPORARY LICENSE AS A LICENSED CLINICAL PSYCHOLOGIST IN RESPONSE TO THE COVID-19 PANDEMIC
Information:
Pursuant to Governor Northam’s Executive Order No. 57 (effective April 17, 2020), a clinical psychologist with an active license issued by another state may be issued an accelerated temporary license by endorsement as a health care practitioner of the same type for which such license is issued in another state upon submission of an application and information requested by the applicable licensing board and the board's verification that the applicant's license issued by another state is active in good standing and there are no current reports in the United States Department of Health and Human Services National Practitioner Data Bank. Such temporary license shall expire ninety (90) days after the state of emergency ends. During such time the practitioner must either seek a full Virginia license or transition patients to Virginia-licensed practitioners.
Clinical psychologists with an active license issued by the Board may provide continuity of care to their current patients who are Virginia residents through telehealth services.
Instructions:
In order to be considered for temporary Virginia Clinical Psychologist license, you must hold an equivalent, active clinical psychology license at the independent level, in good standing with no disciplinary action and no unresolved disciplinary actions against that license or any other mental health or health professional license or certificate.
Complete the application for temporary license as a licensed clinical psychologist form indicating the following information:
a. Demographic information;
b. List of all mental health or health professional licenses or certificates currently or previously held in any jurisdiction;
c. Attestation of having read and agreed to comply with the current Standards of Practice and laws governing the practice of clinical psychology in Virginia; and,
d. Attestation that the applicant understands that the license is for temporary use during the COVID-19 pandemic and will expire 90 days after the state of emergency ends.
Email this application to the Department of Health Professions Behavioral Science Unit at [email protected].
Process:
Once your form has been emailed to [email protected], your application will be processed in the order it is received.
Staff will enter your information into our system, verify your license with each state in which you held or hold a license and complete a National Practitioner Data Bank report (NPDB).
Once staff verifies your information, you will be issued a temporary clinical psychology license with the Virginia Board of Psychology. Your license information will appear on License Lookup on DHP's website. This license will expire 90 days after the state of emergency ends.
9960 Mayland Drive, Suite 300 Henrico, VA 23233-1463 www.dhp.virginia.gov/psychology/
Email: [email protected] (804) 367-4697 (Tel)(804) 767-3626 (Fax)
APPLICATION FOR TEMPORARY LICENSE AS A LICENSED CLINICAL PSYCHOLOGIST IN RESPONSE TO THE COVID-19 PANDEMIC
TO BE COMPLETED BY APPLICANT Applicant Identification & Contact Information Applicant’s Last Name: First Name: Middle/Maiden Name: Suffix:
Social Security Number or Virginia DMV Control Number ___ ___ ___ ___ ___ ___ ___ ___ ___
Date of Birth: (MM/DD/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___
Published Address: This address is subject to public disclosure under the Freedom of Information Act. You may provide an address other than a residence, such as a Post Office Box or practice location if you wish. Address:
City: State: Zip Code: ___ ___ ___ ___ ___
Address of Record: The address information you provide below is your address of record with the Board. Please be advised that all notices from the Board, to include licenses and other legal documents, will be sent to the address of record provided. If you provided a different public address above, this address is not subject to public disclosure under the Freedom of Information Act and will not be sold or distributed for any other purpose. Address:
City: State: Zip Code: ___ ___ ___ ___ ___
Home Number: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Alternate Number: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Email Address:
Licensure History Information: List in order of attainment all the states in which you now hold or have ever held a health or mental health license or certification, whether current or expired. If not applicable, enter N/A
State Type of License/Certificate License/Certificate Number Issued Date Current Status
Certification:. Upon reading this section, please sign and date.
I attest that I have carefully read, understand and will adhere to the laws and regulations Governing the Practice of Psychology in the Commonwealth of Virginia, which are available at https://www.dhp.virginia.gov/psychology/. I understand that this license is for temporary use during the COVID-19 pandemic and will expire 90 days after the State of Emergency ends.
Further, I certify by my signature below that the information provided on this application has been personally provided and reviewed by me, and that statements made on the application are true and complete. I understand that providing false or misleading information, as well as omitting information, in response to information required in this application or as part of the application process is considered falsification of the application and may be grounds for denial of or taking disciplinary action.
SIGNATURE: DATE:
