Other Applications

Qualified Supervisor Application (Medical Psychologists) Information Pursuant to Louisiana Administrative Code, Title 46, Pt. LXIII (“Rule(s)”), §6301, a Qualified Supervisor (“QS”) is a medical psychologist, licensed in accordinace with La. R.S. 37:1360.51 et seq, who is authorized by the Louisiana State Board of Examiners of Psychologists (“Board”) to provide supervised training in Louisiana to a candidate for licensure as a licensed psychological associate, subject to the jurisdiction of the Louisiana State Board of Examiners of Psychologists. Forms Qualified Supervisor Application for Louisiana Licensed Medical Psychologist NOTICE: In compliance with La. R.S. 44:33.1, the LSBEP hereby gives notice that information submitted to the LSBEP may become public record pursuant to the provisions of Louisiana Public Records Law, La. R.S. 44:1, et seq.

Pre-Eligibility Determination Application Information At the time of application for licensure, the LSBEP is authorized and empowered to determine that you meet the criteria under LA R.S. 37:2356 or La. R.S. 37:2356.2, including that you are not “in violation of any of the provisions” of Title 37, Chapter 28. Psychologists, specifically, La. R.S. 37:2359(B)(3), (4) and (7) which may be used as a basis to determine eligibility for licensure under La Revised Statutes, Title 37  §§2351 – 2360 and the board’s rules respecting any such health care provider as set forth in LAC 46:LXIII. Pursuant to LA. R.S. 37:33(A)(1), an individual convicted of a crime may submit a Pre-Application Eligibility Determination Application to request that the LSBEP determine whether an individual’s criminal conviction disqualifies the individual from obtaining a license to engage in the practice of psychology. Pursuant to La. R.S. 37:2950(A)(2), the LSBEP shall consider 1) The nature and seriousness of the offense. 2) The nature of the specific duties and responsibilities for which the license is required. 3) The amount of time that has passed since the conviction. 4) Facts relevant to the circumstances of the offense, including any aggravating or mitigating circumstances or social conditions surrounding the commission of the offense. 5) Evidence of rehabilitation or treatment undertaken by the person since the conviction. Act No. 486 Pre-Application Eligibility Determination Criminal Background Check Information Forms CHRI Intended Use and Privacy Act Statement Pre-Application Eligibility Determination Application NOTICE: In compliance with La. R.S. 44:33.1, the LSBEP hereby gives notice that information submitted to the LSBEP may become public record pursuant to the provisions of Louisiana Public Records Law, La. R.S. 44:1, et seq.

Telesupervision Application Information Use this application to request an exception to the in-person supervision requirement pursuant to LAC 46:LXIII.§1409 – Supervision via Telepsychology. This application is applicable to the supervision of all trainees, including: Postdoctoral Psychology Fellows Predoctoral Psychology Interns Second-Year Practicum Students (or higher) Important Notice Regarding Telesupervision of an Assistant to a Psychologist (ATAP) Disclosure of telesupervision for an Assistant to a Psychologist (ATAP) is included as part of the initial ATAP registration; therefore, a separate application is not required unless the exception was not requested during the initial registration. If telesupervision was not requested or approved on the ATAP’s original application, this form may be submitted to supplement the initial registration and request approval to provide telesupervision. An application fee is required for this supplemental request. Forms Application to Provide Telesupervision NOTICE: In compliance with La. R.S. 44:33.1, the LSBEP hereby gives notice that information submitted to the LSBEP may become public record pursuant to the provisions of Louisiana Public Records Law, La. R.S. 44:1, et seq.

ADA Accommodations Policy American With Disabilities Act (ADA) Policy Forms  ADA Request for Accommodation NOTICE: In compliance with La. R.S. 44:33.1, the LSBEP hereby gives notice that information submitted to the LSBEP may become public record pursuant to the provisions of Louisiana Public Records Law, La. R.S. 44:1, et seq.