Forms: Application & Renewal

LICENSE APPLICATION INFORMATION AND FORMS

GENERAL 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-Eligibility Determination Application to request at any time that the LSBEP determine whether an individual’s criminal conviction disqualifies the individual from obtaining a license to engage in the practice of psychology.  In accordance with La. R.S. 37:2950(A)(2), the LSBEP shall consider all of the following in determining whether a conviction directly relates to the practice of psychology: 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.

APPLICATION FORMS:

TELESUPERVISION

IMPORTANT NOTICE REGARDING TELESUPERVISION OF AN ASSISTANT TO A PSYCHOLOGIST (ATAP): Disclosure of Telesupervision of an Assistant To A Psychologist (ATAP) is included in the initial ATAP Registration and therefore not required in addition to the initial registration. However, if approval for telesupervision was not included in the original application of the ATAP, this form may be used subsequent to the initial registration in order to request approval to provide telesupervision. 

For all other trainees including Postdoctoral Psychology Fellow, Predoctoral Psychology Intern, and Second Year Practicum Student or Higher, use the following application to request an exception to the in person supervision requirements pursuant to LAC:46:lXIII: §1409. Supervision via Telepsychology :