NOVA SCOTIA BOARD OF EXAMINERS IN PSYCHOLOGY

TRANSFER APPLICATION FORM FOR REGISTRATION

UNDER THE PSYCHOLOGISTS ACT (2000) c.32, OF NOVA SCOTIA

NOTE: It is preferred that you complete the MS Word version of this application, but if not, please print legibly.

Name: last ______first ______initial(s) ______

Gender: M __ F __ date of birth: d _____ m ______y ______

Are you legally entitled to work in Canada? ______

Home Address ______

Telephone: ______fax: ______email: ______

Work Address ______

Telephone: ______fax: ______email: ______

Please state the reason you are seeking registration in Nova Scotia ______

Please state the name and address of your Nova Scotia employer(s):______

______

CONTACT INFORMATION FOR PUBLICATION IN THE DIRECTORY OF PSYCHOLOGISTS:

Please Note: We do not recommendthat you include your home address or contact information related to your home, i.e. home phone number, home email, etc. in the Directory. Having accurate information however is helpful for others, i.e. clients or other professionals.

Name:______

Address:______

Telephone: ______fax: ______email: ______

I certify that the statements made by me in this application are complete and correct to the best of my knowledge and belief.

______

Signature Date

Application Fee$250.00: We encourage you to pay the application fee online by visiting the Application section of or you may do so by completing the below section.
Cheque or Money Order enclosed: _____ Visa_____ MasterCard_____ AMEX_____ Paid Online______
Card Number: ______Expiry Date:______
Name on card______Signature to authorize charge: ______
Bachelor's Degree / Master's Degree / Doctoral Degree
Degree Awarded
Dates of Attendance
Date Awarded
Educational Institution
Department
Title of Program
Major Subject
Minor Subject

REFERENCES:

List the name, position, address, and phone number of three referees who are well acquainted with you and your professional work. Two of these referees must be registered or licensed psychologists.

1.Name:

Position:

Address

Phone number______

2.Name:

Position:

Address

Phone number______

3.Name:

Position:

Address

Phone number______

BACKGROUND QUESTIONAIRRE

Please answer the following questions by checkingYes or No and filling in the blanks if/where appropriate.

If the answer to any of the questions is yes, then please provide the details on a separate sheet.

Have you ever:
Had an application for registration, certification or licensing as a psychologist or in another profession rejected? / Yes / No
Been found in violation of ethical principles by an ethics or professional practices board in relation to psychology or another profession? / Yes / No
Voluntarily surrendered a professional credential in response to an ethics charge in relation to psychology or another profession? / Yes / No
Received disciplinary action from an ethics or professional practice board in relation to psychology or another profession? / Yes / No
Been notified of any pending disciplinary action from an ethics or professional practice board in relation to psychology or another profession? / Yes / No
Had a professional credential revoked, suspended or limited by an ethics or professional practices board in relation to psychology or another profession? / Yes / No
Been convicted of, or pleaded guilty to a summary conviction offense or an indictable offense, other than a minor traffic offense, in a federal or provincial court? / Yes / No
Received formal disciplinary action by an employer or supervisor based wholly or in part on ethical issues? / Yes / No
Held or do you currently hold registration or a license in another profession other than psychology? / Yes / No
If yes to above,
What profession? ______
What is the current status of said registration? ______

I understand that the Board may request any further information it may consider necessary in order to evaluate this application.

SignatureDate

RELEASE of INFORMATION

Please complete the release below for any jurisdiction(s) in which you are currently registered as a Psychologist. Those registered in more than one jurisdiction should complete a copy of this Release of Information form for each jurisdiction.

RELEASE of INFORMATION:

This is to confirm that I give consent to NSBEP to contact:

______

Name of Psychology Regulatory Body

to obtain information regarding my registration.

______

Applicant’s Name

______

Applicant’s Signature Date

Name of agency/ board

Address of agency/board

Date of original registration/license

Certificate/License/number

Specialty area (if designated):

Is the certificate/license current? Yes No

OTHER REQUIREMENTS:

You are required to:

  1. Submit an up-to-date Curriculum Vitae
  2. Submit a photocopy of at least one piece of Photo Identification.(e.g. Driver's license, Passport)
  3. Submit a Criminal Record Check. Contact your local police or you might contact CSI, a company that completes international background checks to see if a background check would be available for your country of residence. The link is directly below:
  1. Submit a Child Abuse Registry Checkfrom the jurisdiction where you reside.

Note: If you are applying from a Province, State or Territory that does not maintain a separate Child Abuse Registry or does not allow disclosure of information to NSBEP, you are required to sign the declaration below:

child abuse Declaration

Part 1 (All applicants must complete Part 1)

I certify that I have not been censured, reprimanded or found by a court to have abused children.

______

Signature

Part 2 (Complete Part 2 if a separate Child Abuse Check is either unavailable in your jurisdiction or cannot be disclosed to the Nova Scotia Board of Examiners in Psychology, i.e., some jurisdictions may not intend for their registry checks to be used for the purpose of gaining registration outside of their jurisdiction.)

I reside in a jurisdiction that, to the best of my knowledge, either does not maintain a Child Abuse Registry Check separate from a Criminal Record Check, or the agency maintaining this information cannot disclose such information to the Nova Scotia Board of Examiners in Psychology, or registry checks are not intended for the purpose of gaining registration outside of the jurisdiction.

______

Signature

If requested, you may be placed on the courtesy register until the transfer interview is completed. Please note: The Confirmation of Standing Form (next page) must be completed by the jurisdiction(s)in which you are registered and received by NSBEP prior to placement on the Courtesy Register.

CONFIRMATION OF STANDING FORM

This form must be completed by all jurisdictions in which you are registered as a Psychologist.

Please provide a copy to each applicable jurisdiction with instructions for the completed form to be sent directly to NSBEP. It is your responsibility to provide this form to all applicable jurisdictions and pay any associated fees.

In order to facilitate the transfer of

______

to the Nova Scotia Board of Examiners in Psychology –NSBEP would you please provide the following information:

Registration/Certificate #:______Date issued:______

Registration/Certification Status:______Expiration Date:______

Approved areas of psychological practice: (e.g. Clinical, School, etc.)

______

Approved service populations: (e.g. Children, Adults, etc.)

______

Are there any conditions or restrictions on the Registrant? YES____ NO____

If yes please explain:

Are there any past or outstanding complaints? YES_____ NO ______

If yes please explain:

Has the Registrants registration/certification ever been revoked or suspended? YES_____ NO______

If yes please explain.

Did the Registrant complete a Criminal Records Check and Child Abuse Register Check?

YES_____ NO_____

Are original transcripts on file? YES______NO______

Has the Registrant passed the EPPP? YES______NO______Mark if available______

Was the Registrant assessed on:

a. The Core Competencies? YES______NO_____

b. On Foundational Knowledge? YES______NO_____

Verified by:

Signature: ______Date:______

Name: ______

Position: ______

Board / Agency: ______

Thank you for completing this form. To expedite the transfer process it may be faxed to NSBEP at:

1-902-423-0058

Please forward the original document to:

The Nova Scotia Board of Examiners in Psychology

Suite 455, 5991 Spring Garden Road

Halifax, Nova Scotia B3H 1Y6

Psychological Practice Profile Instructions

Part A asks about your employment status, practice setting(s), and language(s)*. Please indicate whether your employment status is full or part time. (Those working part time please indicate how many hours per week.) Then check the applicable practice setting (s) in which you are employed and identify the applicable languages in which you are comfortable providing services.

*Information about language(s) of service is helpful for the public, e.g. NSBEP Directory of Psychologists (listing by language), Directory of French Speaking Health Care Providers.

Part B of the Psychological Practice Profile asks you to check the area(s) of your psychological practice and estimate the percentage of time you spend working in each area. For instance, if you spend four days per week engaged in clinical work and one day per week doing research, you would check #1, Clinical, and #5, Research. You would then write in 80% for Clinical and 20% for Research. The total percentage of time should add up to 100%.

Part C of the Psychological Practice Profile asks you to indicate the activities and services you provide within the areas of practice indicated in Part B. For instance, if your clinical work involves Consultation, Assessment/Evaluation, and Intervention/Treatment with Adults you would enter #1 in the appropriate boxes for Adults. Likewise, if your research was with adults, you would enter #5 in the box corresponding to Research and Adults.

Some Clarifications

Withinthe category of Consultation, NSBEP is interested in the time spent completing any work done on behalf or at the request of another health professional. For instance, a GP might be concerned that one of his patients is depressed, and asks for your opinion. The time spent talking to the GP to clarify the concerns and time providing feedback after seeing the patient would be entered under Consultation.

With the category of Assessment,NSBEP is interested in the time you spend completing both psychometric assessment and non-psychometric assessment function, i.e. in order to provide an understanding which informs a practical plan of action.

Some individuals may confuse clerical work with Administration. Time spent completing any clerical work should not be assigned to the category of Administration (as previously noted we are referring to managing a psychological service unit when using the term Administration). Rather, such work should be assigned to the corresponding activity category. For instance, if you are completing clerical paperwork in relation to an assessments you have completed, this should be entered in the Assessment / Evaluationcategory. Similarly, if your paperwork is in relation to an intervention then it should be captured under the Intervention / Treatment category.

In addition to one’s declared area of applied practice, one may be engaging in formal research or teaching psychology courses. As such, the Board has included the areas of Formal Research and Academic Psychology.

Withinthe category of Formal Research, NSBEP is interested in capturing the time you spend completing formal research work (versus the time spent developing and maintaining competence). Time spent developing and maintaining competence, etc., should be captured but assigned to the corresponding activity category. For example, time spent reviewing literature on interventions would be entered in the Intervention/Treatment category.

The Board has also included a category for Administration since a number of psychologists hold such positions.Within the category of Administration, NSBEP is not referring to the completion of general administrative work (such as paperwork), rather we are referring to psychologists who hold a position in which they manage a psychological service unit.

The Board’s defined areas of practice are available via the NSBEP document entitled Appropriate Practice Areas which can be accessed via this link:

The categories of Formal Research& Academic & Administration are included in both SectionsA & C of the Psychological Practice Profile so that the corresponding populations can be tracked for these areas.

PSYCHOLOGICAL PRACTICE PROFILE

A. Please affirm your overall employment status, all practice setting, and language(s).

Overall I will be employed: Full-timePart-time Not currently working

If employed part-time, how many hours per week will you average?: ______

In the area below, please check the applicable practice setting(s) in which you will be employed.

Private Practice / Community Agency / Hospital / School
Counselling Centre / University/College / Government / Other
You are comfortable to provide services in: English ___, French ___, other language(s)______

B. In the area below, check the applicable area(s) of your intended psychological practice[1] and indicate the percentage of your time spent working in the area(s).

  1. Clinical Psychology
/ 2. Counselling Psychology
  1. School Psychology
/ 4. Forensic/ Correctional Psychology
  1. Formal Research
/
  1. Academic (teaching psychology)

  1. Industrial / Organizational Psychology
/
  1. Clinical Neuropsychology

  1. Administration

C. Once you have indicated your area(s) of practice, place the corresponding number(s) in the below table to identify the activities and services you will provide and the clients to whom you will provide these services.

Clients / Administration / Consultation / Assessment/ Evaluation / Intervention/ Treatment / Formal Research / Academic
Infants
Children
Adolescents
Adults
Elderly
Families
Couples
Organizations

Print NameDate

Applicant’s Signature

APPLICANT CHECKLIST

Please forward all documentation to:

The Nova Scotia Board of Examiners in Psychology

Suite 455 - 5991 Spring Garden Road Halifax, NS B3H 1Y6

Have you?

  1. Completed payment online or included payment with your completed application form?
  2. Included a copy of your curriculum vitae?
  3. Included a copy of your official photo identification? (e.g. Driver's license, Passport)
  4. Either ordered your Criminal Record Check using the suggested online process or requested it from police (which you will then need to send to NSBEP)?
    Please note: if your criminal record check included a vulnerable sector check or screening, it does not replace the need for you to follow the below requirements concerning Child Abuse.
  5. Completed Part 1 of the Child Abuse Declaration?
  6. Either ordered your Child Abuse Check (which you will then need to send to NSBEP), or if applicable, completed Part 2 of the Child Abuse Declaration?
  7. Forwarded the Confirmation of Standing Form to all psychology regulatory bodies in which you hold registration and requested that they send verification of your good standing directly to NSBEP?
  8. Provided an email address? We generally communicate the results of an approved
    application by email.

Rev. September 2014

Page 1 of 11

[1] The Board recognizes that subspecialty areas of practice are evolving (e.g. Health Psychology, etc.) but such areas should correspond with the broader practice areas (e.g. Clinical Psychology).