APPLICATION FOR ENDORSEMENT AS AN INDEPENDENT … · Indiana Association of School Psychologists. 125 West Market Street, Suite 300 . Indianapolis, IN 46204 . Please type or print

125 W. Market Street

Suite 300

Indianapolis, IN 46204

(866) 518-4472 or (317) 472-6955

www.iasponline.org

Dear School Psychologist:

Enclosed is information regarding the application process for an independent practice endorsement (IPE) in Indiana.

You have two years to complete the application process. Please make copies of all materials being submitted with your

IPE application for your record keeping.

Enclosed:

An application checklist

Application for endorsement

Form A

Form B

Form C

Form D

Please complete all forms listed above and submit with your application. The following are the requirements for

obtaining your IPE. Additional information can be found at IC 20-28-12-3 or on the IASP website at

http://iasponline.org.

1. You must be a licensed school psychologist in Indiana

2. You must be employed as a school psychologist at least 30 hours a week (Form B)

3. You must provide a copy of your transcript showing:

a. At least 60 graduate semester hours or 90 quarter hour master’s or specialist degree in school

psychology

b. 1200 hours internship at least 600 hours must be in a school setting

4. You must provide documentation of 1200 hours (after graduation not including your internship) at least 600

which must be in a school setting of supervised experience by a physician, a psychologist, or a school

psychologist with an IPE or NCSP (Form A)

5. You must provide documentation/certificate of 12 hours of training provided by an HSPP or a psychiatrist in the

identification and referral of mental and behavioral disorders (this can be obtained by attending the DSM

course offered by IASP in even numbered years)

6. You must provide documentation of 10 case studies or evaluations requiring the identification or referral of

mental or behavioral disorders. (Form C)

7. You must provide documentation of 30 hours of supervision with a physician, a psychologist, or a school

psychologist with an IPE or NCSP. These hours must be completed within 24 months but not less than 6

months and cannot include more than 1 hour per week

8. You must provide documentation of passing PRAXIS exam or NCSP

All forms should be submitted together to the IASP office at the above address. If you have any questions regarding the

application process or requirements, please contact Kim Williams via phone (866) 518-4472 or e-mail

[email protected].

Once your application has been approved by IASP you will receive notification so you can apply online with the Indiana

Department of Education to add the IPE to your state license.

Checklist for Independent Practice Endorsement Application. Complete and return with your application.

Name ___________________________________________________

Address __________________________________________________________________________________________

I am a licensed school psychologist in Indiana I am employed as a school psychologist at least 30 hours a week (Form B) Copy of transcript showing:

o At least 60 graduate semester hours or 90 quarter hour master’s or specialist degree in school psychology

o 1200 hours internship at least 600 hours must be in a school setting Documentation of 1200 hours

(after graduation not including your internship) at least 600 which must be in a school setting of supervised

experience by a physician, a psychologist, or a school psychologist with an IPE or NCSP (Form A)

Documentation/certificate of 12 hours of training provided by an HSPP or a psychiatrist in the identification and referral of mental and behavioral disorders (this can be obtained by attending the

DSM course offered by IASP)

Documentation of 10 case studies or evaluations requiring the identification or referral of mental or behavioral disorders. (Form C)

Documentation of 30 hours of supervision with a physician, a psychologist, or a school psychologist with an IPE or NCSP. These hours must be completed within 24 months but not less than 6 months and cannot include more than 1 hour per week (Form D)

Documentation of passing PRAXIS exam or NCSP

APPLICATION FOR ENDORSEMENT FOR INDEPENDENT PRACTICE

IASP office use only Action Recommended: The applicant is recommended for the independent practice endorsement. The applicant did not meet application requirements. Application is incomplete. Needed: __________________________________________________ IPE #______________________ IPE Exp Date: ____________________________________

Reviewed by: Name Date

APPLICATION FOR ENDORSEMENT AS AN INDEPENDENT PRACTICE SCHOOL PSYCHOLOGIST Return completed application materials to

Indiana Association of School Psychologists 125 West Market Street, Suite 300

Indianapolis, IN 46204 Please type or print legibly. Telephone number: (317)472-6955, (866)518-4472

Directions: Answer all questions. Return this application along with all items on the checklist to the address above.

1. Name of applicant [last, first, middle, (maiden)]

2. Address (number and street, city, state, ZIP code)

3. Home telephone number (include area code)

Work telephone number (include area code)

4. E-mail address

5. Date of birth (month, day, year)

6. Indiana Professional Educator’s License number (Please enclose a copy of your current license)

7. Nationally Certified School Psychologist number (Please enclose a copy of your current NCSP card or certificate, if applicable.)

8. Education: Please complete in order of highest degree first, followed by other degrees. Include graduate and undergraduate education.

INSTITUTION LOCATION

(City, State)

DATES OF ATTENDANCE

(mm,yy) DEGREE TITLE/AREA

GRADUATE SEMESTER HRS

*Please enclose transcript of graduate work.

9. Employment History. Please list places of employment for the past 10 years.

NAME AND ADDRESS OF EMPLOYER TITLE HRS OF

EMPLOYMENT PER WEEK

DATES OF EMPLOYMENT (mm/yy) to (mm/yy)

*Please provide written documentation from all employers verifying this information (see Form B)

10. Retirement Exemption:

Name of last employer

Date last employed

Address of last employer (number and street, city, state, ZIP code)

Name of most recent supervisor

Telephone number

Address of most recent supervisor (number and street, city, state, ZIP code).

11. Medical Exemption:

Name of attending physician

Address of attending physician (number and street, city, state, ZIP code)

Date and nature of disability. Please send any records pertinent to your request for a medical exemption.

Please answer the following questions. If you answer “Yes” to ANY of these questions explain fully, in a sworn affidavit, including all relevant details. Describe the event including location, date, and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of an endorsement.

12. Has disciplinary action ever been taken regarding any school psychology license, certificate, registration, or permit you hold or have held? Yes No

13. Have you ever been denied a license, certificate, registration, or permit to practice school psychology or any regulated health or school occupation in any state or country? Yes No

14. Are you now being, or have ever been treated for a drug abuse or alcohol problem? Yes No

15. Have you ever been convicted, pled guilty to, pled nolo contendre to: a. A violation of any federal, state, or local law relating to the use, manufacturing, distribution, or dispensing of controlled substances or

illegal drugs? Yes No b. Any offense, misdemeanor, or felony in any state? (Except minor violations of traffic laws resulting in fines.)

Yes No 16. Have you ever been denied staff membership or privileges in any hospital, health care facility, or education facility or had such privileges

revoked, suspended, or subjected to any restrictions, probation, or other type of discipline or limitations? Yes No

17. Have you ever been admonished, censored, reprimanded, or requested to withdraw, resign, or retire from any hospital, health care facility, or educational facility in which you have trained, held staff membership or privileges, or acted as a consultant?

Yes No

18. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes No

Please answer the following questions in regard to your completion of the IPE requirements. (Please submit the appropriate documentation: transcript, Forms C and D.) 19. Have you successfully completed at least 1200 hours of school psychology experience after completion of graduate degree requirements

(and not including the internship required for degree completion or licensing)? Yes No

20. Have you completed thirty (30) hours of supervision within 24 consecutive months but not less than six (6) months, with not more than one (1) hour of supervision per week? Yes No

21. Have you completed ten case studies and/or evaluations requiring the identification or referral of mental or behavioral disorders during the time of supervision? Yes No

22. Have you completed 12 hours of training in the identification and referral of mental and behavioral disorders provided by a health service

professional in psychology (HSSP) or psychiatrist? Yes No

APPLICATION AFFIRMATION

I hereby swear under penalty of perjury that the above information and statements are true, complete, and correct and that I will uphold the ethical standards as set forth by the National Association of School Psychologists.

Signature of applicant

Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization, or institution to release to the Indiana Department of Education any files, documents, records, or other information, pertaining to the undersigned, requested by the Board or any of their authorized representatives in connection with processing my application for endorsement as an independent practice school psychologist. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, persons, and institutions from any liability with regard to such inspection or furnishing of such information. I further authorize the Indiana Department of Education or any of their authorized representatives to disclose to the aforementioned organizations, person, and institutions any information which is material to my application, and I hereby specifically release the Indiana Department of Education or its representatives from any and all liability in connection with such disclosures. A photocopy of this authorization has the same force and effect as the original.

AFFIRMATION

Signature of applicant

Date (month, day, year)

FORM A – VERIFICATION OF SUPERVISED EXPERIENCE Applicant instructions: Please complete the top section of this form, then forward it to your post-graduate supervisor. You are authorized to photocopy this form if necessary.

Name of applicant [last, first, middle, (maiden)]

Address (number and street, city, state, ZIP code)

Telephone number (home) Date of birth (month, day, year)

I hereby authorize __________________________________ to furnish the Indiana Department of Education and the Indiana Name of supervisor

Association of School Psychologists with the information below.

Signature of applicant Date (month, day, year)

SUPERVISION INFORMATION

Supervisor instructions: Complete the remainder of this form and return to applicant.

Name of Supervisor (last, first, middle)

Title

Name of business/school Telephone number

E-mail address

NCSP # (if applicable)

Business address

IPE or HSPP # (if applicable)

Professional Educator’s License #

Expiration date of Indiana license:

APPLICANT EMPLOYMENT INFORMATION

Applicant’s job description during time of your supervision:

Beginning and ending dates of IPE supervision:

Has the applicant successfully completed at least 1200 hours of school psychology experience after completion of graduate degree requirements (and not including the internship required for degree completion or licensing) ) at least 600 which must be in a school setting of supervised experience by a physician, a psychologist, or a school psychologist with an IPE or NCSP)? Yes No

Has the applicant completed thirty (30) hours of supervision within 24 consecutive months but not less than six (6) months, with not more than one (1) hour of supervision per week? Yes No

Has the applicant completed ten case studies and/or evaluations requiring the identification or referral of mental or behavioral disorders during the time of supervision? Yes No

Please provide a brief description of how the supervision was conducted.

The above indicated supervision was performed by me pursuant to my order, control, and full professional and legal responsibility as a supervisor. I do hereby declare that the information contained herein is true and correct.

Signature of supervisor Title Date (month, day, year)

FORM B – VERIFICATION OF EMPLOYMENT / EXPERIENCE Applicant instructions: Please complete the top section of this form, then forward it to your employer. You are authorized to photocopy this form if necessary.

Name of applicant [last, first, middle, (maiden)]

Address (number and street, city, state, ZIP code)

Telephone number (home) Date of birth (month, day, year)

Name of Supervisor (last, first, middle)

Title

Name of business

Business address (number and street, city, state, ZIP code)

I hereby authorize ________________________________ to furnish the Indiana Department of Education and the Indiana (name of employer) Association of School Psychologists with the information below.

Signature of applicant Date (month, day, year)

Employer instructions: Complete the remainder of this form and return to applicant.

Name of business / institution where employed

Type of facility: Developmental Center Mental Health Center State Hospital Public/Private Hospital Public/Private School Rehabilitation Center

Address (number and street, city, state, ZIP code)

Telephone number Fax number

Date employment began Date employment ended (if currently employed, please indicate)

Position held Hours worked per week during the contract period

The above indicated experience has been performed by the applicant pursuant to my order, control, and full professional and legal responsibilities as an employer. I do hereby declare that the information contained herein is true and correct.

Signature of employer Title Date (month, day, year)

Telephone number

E-mail address

FORM C – CASE STUDIES Provide documentation of 10 case studies or evaluations requiring the identification or referral of mental or behavioral disorders.

Applicant Name ______________________________________________________________________ Supervisor Name ______________________________________________________________________ Site of Supervision ______________________________________________________________________ Date Supervision Began __________________________ Date Ended ________________________

Student Initials Dates of Consultation Behavior/Mental Health Concern

Applicant Signature __________________________________________________Date ____________ Supervisor Signature _________________________________________________ Date ____________

FORM D – SUPERVISION LOG SUMMARY Only one hour per week. Must be within 24 months/not less than six months. Total hours should equal 30.

Applicant Name ______________________________________________________________________ Supervisor Name ______________________________________________________________________ Site of Supervision ______________________________________________________________________ Date Supervision Began __________________________ Date Ended ________________________ Record actual dates of one-hour face-to-face supervision below:

Applicant Signature __________________________________________________Date ____________ Supervisor Signature _________________________________________________ Date ____________