Licensee Forms

Active Licensees:

Licensed Psychological Examiner – 395
Licensed Psychological Examiner – Independent Status – 267
Licensed Psychologist – 606

Licensees and Applicants – Utilize the links on the left-hand side of the page for forms related to your licensure status.

• Complaint Form
• 2019-2020 Vol Inactive Renewal
• 2019-2020 Renewal Paper Forms

License Verification:

• ONLINE LICENSE VERIFICATION
• Paper License Verification Form

Psychologists Forms

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews.The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

• Supervision Report Form
• Statement of Intent to Practice as a Psychologist
• Supervision Agreement and Plan
• Application for Supervisor Status
  • 2019-2020 Renewal Paper Forms

Licensed Psychological Examiner Independent Status Forms

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

• Supervision Report Form
• Licensed Psychological Examiner Independent Status Information
• Licensee Supervision Completion – PE Independent Practice
• Statement of Intent LPE-Independent Status
• Supervision Agreement and Plan
• Supervision Log
• 2019-2020 Renewal Paper Forms

Licensed Psychological Examiner Forms

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

• Supervision Report Form
• Statement of Intent LPE
• Supervision Agreement and Plan
• Supervision Log
• 2019-2020 Renewal Paper Forms

Provisional Licensees Forms

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

• Provisional License Payment Form
• Provisional License Supervision Log
• Psychologist Postdoctoral Supervision Form
• Statement of Intent Provisionally Licensed Psychologist
• Supervision Agreement and Plan
• Supervision Report Form

Technicians Forms

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

• Technician Supervision Report Form
• Technician Registration Request Form

New Applicants

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

• Application Request Form

Mobility Programs & Forms

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

Application Packets Available:

• Psychologist (Doctoral level only)
• Psychologist – Upgrade (Psychological Examiners only)
• Senior Psychologist (Doctoral level only)
  Must be licensed 20+ years.
• National Register (Psychologists only)
  Must be licensed 5+ years and be a member of National Register.
• Certificate of Professional Qualification in Psychology (CPQ) (Psychologist only)
  Must be licensed 5+ years in a participating state.
• Technician Registration Form

Voluntary Inactive/Retired Licensees

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

Board Meeting Agenda Items: If you would like to have an item on the Board meeting agenda, it must be in the office by the 1st of the month. The request must be submitted in writing and mailed to the Board office. Facsimiles and e-mails will not be accepted.

This includes applications for credential reviews. The application must be complete and ready for review by the 1st of the month to be considered at the Board meeting.

Mailing List

Forms must include a cover letter with each submission. Incomplete submissions will not be processed by the Board nor will the incomplete submission be returned to you.

• Mailing List Request Form

We accept credit card payments.  Payment information is included on the form.

Charge: $100.00 for a mailing list of active licensed Psychologists and Psychological Examiners in Arkansas.

The mailing list will be in Excel and will consist of the following for active and voluntary inactive licensees: