T H E C O L L E G E O F P S Y C H O L O G I S T S O F O N T A R I O L'O R D R E D E S P S Y C H O L O G U E S D E L ' O N T A R I O

T H E C O L L E G E O F P S Y C H O L O G I S T S O F O N T A R I O L'O R D R E D E S P S Y C H O L O G U E S D E L ' O N T A R I O 110 Eglinton Avenue West, Suite 500, Toronto, Ontario M4R 1A3 Tel (416) 961-8817 Fax (416) 961-2635 Email: cpo@cpo.on.ca * Website: www.cpo.on.ca APPLICATION FOR CERTIFICATE OF REGISTRATION AUTHORIZING AUTONOMOUS PRACTICE (In accordance with Sections 22.16 to 22.21 of the Health Professions Procedural Code) For Applicants Currently Registered to Practise Psychology in a Canadian Province or Territory January 2017

TABLE OF CONTENTS A B C D E F G PERSONAL IDENTIFICATION...3 CURRENT AND PREVIOUS REGISTRATION/LICENSURE... 4 DECLARATION OF COMPETENCE.7 THE CONTROLLED ACT OF COMMUNICATING A DIAGNOSIS...8 EXAMINATION ACCOMMODATION.......9 AUTHORIZATIONS...15 APPLICATION EXPIRY......15 H J REGISTRATION VERIFICATION FORM PART 1 16 REGISTRATION VERIFICATION FORM PART 2 17 Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 2

A PERSONAL IDENTIFICATION A1 Date of Application: Indicate the date that you intend to begin providing psychological services in the province of Ontario: A2 Surname: First Given Name: Middle Name(s): Surname(s) or Given Name(s) under which you have previously been trained or employed: Home Address: Home Telephone: Business Address: Business Telephone: Preferred Mailing Address: Home Work E-mail for College use: E-mail for Public use: Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 3

B CURRENT AND PREVIOUS REGISTRATION/LICENSURE B1 Please provide information on all provinces, territories, and /or states where you currently hold registration or a licence to practise psychology: Jurisdiction Year Certified Certificate Number Professional Title (Psychologist or Psychological Associate) Expiration Date B2 Please provide information on all provinces, territories, and /or states where you have previously held registration or a license to practise psychology: Jurisdiction Year Certified Certificate Number Expiration Date You are required to request that the regulatory board of the jurisdiction(s) listed in Sections B1 and B2 send directly to the College of Psychologists of Ontario a completed Registration Verification Form (See forms in Appendix A and Appendix B) Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 4

B3 Please provide information about the degree upon which this application is based. Institution Degree awarded (e.g. M.A., Ph.D.) Year degree awarded Name of program (e.g. clinical psychology) B4 B5 B6 B7 B8 B9 B10 Has any diploma, certificate or licence relating to the profession of psychology or another health profession granted to you ever been suspended, revoked or made subject to terms or conditions? If yes, append details. Have you ever been convicted of professional misconduct, incompetence, or incapacity in any jurisdiction in relation to another health profession, or in any jurisdiction in relation to the profession of psychology? If yes, append details. No Have you ever been found to have committed professional negligence or malpractice by a court or tribunal? Are you currently named as a defendant in any civil proceeding in which professional malpractice or negligence is alleged? Are you currently the subject of any inquiry, investigation or proceeding, in any jurisdiction in relation to another health profession, or in relation to the profession of psychology in respect of allegations of professional misconduct, incompetence, or fitness to practise/incapacity? If yes, append details. Have you ever been censured or reprimanded for sexual harassment or sexual misconduct? Have you ever been found guilty of academic dishonesty by a post-secondary educational institution? Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 5

B11 B12 B13 B14 B15 B16 B17 Have you ever been suspended or expelled from any post-secondary educational institution? Are you now abusing, dependant on, or being treated for the abuse or dependence on alcohol or a drug? Have you ever abused, been dependant on, or been treated for the abuse or dependence on alcohol or a drug? Have you ever been denied any license, certificate, registration or permit due to lack of good character? Have you ever been suspended, disqualified, censured, or disciplined as a member of any professional organization? Have you ever been dismissed from or asked to resign from any employment due to negligence, professional misconduct or academic dishonesty? Is there any event, circumstance, condition or matter not disclosed in your replies to the preceding questions touching upon your conduct, character or fitness to practise that might be an impediment to your registration as a psychologist or a psychological associate? Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 6

C DECLARATION OF COMPETENCE Below, please indicate your area(s) of competence for the practice of psychology in Ontario Activities and Services Assessment / Evaluation Intervention/ Consultation Research Teaching Clinical Psychology Counselling Psychology School Psychology Area(s) Forensic/Correctional Psychology Clinical Neuropsychology Health Psychology Rehabilitation Psychology Industrial/Organizational Psychology Client group(s): Children Adults Seniors Adolescents Couples Families Name (please print): Organizations Date: Signature: Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 7

D THE CONTROLLED ACT OF COMMUNICATING A DIAGNOSIS Chapter 18, Section 27.(2) of the Regulated Health Professions Act states: (2) A controlled act is any one of the following done with respect to an individual: 1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely upon the diagnosis. Section 4. of the Psychology Act, 1991, states: In the course of engaging in the practice of psychology, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to communicate a diagnosis identifying, as the cause of a person s symptoms, a neuropsychological disorder or a psychologically based psychotic, neurotic or personality disorder. If your declaration of competence specifies solely the area of industrial/organizational psychology, you do not need to complete the following section. If you declare one or more of the other practice areas, you must complete this section. Please indicate whether you are authorized to formulate and communicate a psychological diagnosis in the Canadian province or territory you are currently registered in: No If No, please provide details: Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 8

E EXAMINATION ACCOMMODATION In the section below, please indicate whether you have a documented impairment or disability which will require accommodation during the writing of the Jurisprudence and Ethics Examination (JEE). NO, I do not have a documented impairment or disability which will require accommodation when taking examinations. YES, I do have a documented impairment or disability which will require accommodation when taking examinations. If you have indicated YES in the section above, you are required to submit appropriate documentation from a currently registered medical doctor, psychologist, psychological associate or other regulated health professional who has specific training, expertise and experience in the diagnosis of the condition(s) for which the accommodation is being requested. This must be provided directly to the College on Form 1 (Form 1 can be found on the following page after Section E) Alternatively, if you received accommodation during completion of your university program(s), you may provide documentation from the university from which you completed the highest psychology degree (e.g. Master s or PhD program) which you are submitting to the College as part of your application for registration. This documentation must be completed by an appropriate representative of Student Support Services/Access Office of the university you attended, provided directly to the College on Form 2 (Form 2 can be found on the following page after Form 1). Please indicate which, if any, of the available accommodations you would like to request. If your disability or impairment requires an accommodation that is not specified in the list below, please indicate Other* and contact the Senior Registration Assistant at the College at: exams@cpo.on.ca or 416-961-8817 ext. 222. Standard Accommodations for the JEE include: Extra Time: Additional 30 minutes of writing time Other JEE Accommodations include: Separate Room Large Print Examination Reader and/or Person to enter answers (with separate room) Sign-Language Interpreter (with separate room) Service Animal (with separate room) Access to medication and/or glucose meter Access to food and/or beverage Other*: IMPORTANT NOTE: IN ALL CASES, DOCUMENTATION, EITHER FROM YOUR REGULATED HEALTH CARE PROFESSIONAL OR THE UNIVERSITY FROM WHICH YOU GRADAUTED, MUST BE SUBMITTED TO THE COLLEGE AT LEAST 60 CALENDAR DAYS IN ADVANCE OF AN EXAMINATION ADMINISTRATION IN ORDER TO ALLOW SUFFICIENT TIME FOR YOUR REQUEST TO BE REVIEWED AND FOR ACCOMMODATIONS TO BE ARRANGED. Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 9

Documentation must specifically support the accommodation(s) being requested, by identifying: a) how the identified disability or impairment impacts the ability of the candidate to successfully participate in the examination, and b) how the requested accommodation(s) mitigate(s) the disability or impairment within the specific context of the examination. Acknowledgements and Consent: I acknowledge that I have read the College of Psychologists of Ontario s Accommodations Policy. I confirm that all the information on this form and any attached documentation is true and correct to the best of my knowledge and belief. I consent that the information contained herein and in any related documents (Form 1 or 2 and related documentation) provided to the College of Psychologists of Ontario for the purpose of supporting my request for accommodation may be reviewed by a third-party such as a psycho- educational consultant in order to determine appropriate accommodations. I acknowledge that the personal information provided on this form is used by the College to administer the Regulated Health Professions Act, 1991, the Psychology Act, 1991 and its Regulations related to the governance of the psychology profession in Ontario. Information is collected, used, and disclosed in accordance with the College s Privacy Code. Print Name Signature Date Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 10

FORM 1 Examination Accommodation: Medical Documentation The College of Psychologists of Ontario Form to be completed in its entirety by a licensed/registered regulated health professional, attached to a current medical report and returned directly to the College. The College requires this document as well as a current medical report relevant to the request for accommodation submitted by a licensed/registered regulated health professional who is competent to provide an assessment of the disability or impairment for which accommodation is being requested. Documentation is considered current when the candidate has been assessed within the most recent six months for temporary disabilities, or within the last three years for permanent disabilities. This form must be returned to the College, along with a complete medical report, to the College at least 60 calendar days before the examination or focused d interview date. Please note that the College does not need to receive a diagnosis and that only health information relevant to the candidate's need for and request for accommodation should be included. Please return by mail, e-mail or fax to: Myra Veluz, Senior Registration Assistant The College of Psychologists of Ontario 110 Eglinton Avenue West, Suite 500 Toronto, Ontario M4R 1A3 Tel: (416) 961 8817, Ext. 222; 1-800 489 8388, Ext. 222 E-mail: exams@cpo.on.ca Fax: (416) 961 2635 Candidate's full name (printed): Name of health professional (printed): Applicants to the College of Psychologists of Ontario are required to pass three entry-to-practice examinations as part of the registration process. 1. The Examination for Professional Practice in Psychology (EPPP) is a computer-based multiple-choice examination, which consists of 225 questions. Candidates are allowed four hours and 15 minutes to complete it. The EPPP is administered through an exam vendor, Pearson VUE on an on-going basis throughout the year at Pearson VUE testing sites in Canada and the United States. All candidates may have access to, and therefore do not have to request: - an adjustable armless chair; - adjustable font size; - ergonomic chair; and - ergonomic keyboard. 2. The Jurisprudence and Ethics Examination (JEE) is a two-hour written (paper and pencil) multiple-choice examination that consists of 60 questions. It is held at several examination centers in Ontario. 3. The Oral Examination: Once applicants have passed the EPPP and JEE and have met all the requirements, they will be invited to attempt the Oral Examination. The Oral Examination is a onehour in-person interview conducted by a team of three members of the College. Focused Interview Members of the College may be required to attend a focused interview if they are requesting changes to their certificate for registration. Such changes could include requesting a change or removal of a term, limit or condition and/or the expansion or addition of areas of competence. These one-hour interviews are conducted by a team of three members of the College, usually in an in-person setting. While the focused interview is not a formal examination, it is an assessment activity for which the College will provide accommodation consistent with the College s Examination Accommodation Policy. Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 11

1. Please describe the credential(s) which qualify you to diagnose and/or verify the candidate s disability or impairment and to recommend the testing accommodations: 2. Last date of assessment/treatment/consultation with candidate: 3. What is the nature of the disability or impairment that requires testing accommodations? (Please note that the College does not need to receive a specific diagnosis.) 4. Is this a permanent condition? YES NO 5. If no, when is the disability or impairment likely to abate? 6. How does the disability or impairment affect the candidate s ability to perform under the standard testing conditions as described for the EPPP, JEE, Oral Examination and/or focused interview? 7. What accommodation(s) do you recommend the candidate request to mitigate the disability or impairment within the specific context of the examination(s) and/or focused interview? I confirm that all the information on this form and the attached medical report is true and correct to the best of my knowledge and belief. I am aware that the information contained herein may be reviewed by a third-party such as a psycho-educational consultant in order to determine appropriate accommodations. I acknowledge that the personal information provided on this form is used by the College to administer the Regulated Health Professions Act, 1991, the Psychology Act, 1991 and its Regulations related to the governance of the psychology profession in Ontario. Information is collected, used, and disclosed in accordance with the College s Privacy Code. Name of health professional (print): Signature of health professional: Title: Address: Email address: Telephone number: License/Certificate Number: Date: Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 12

FORM 2 Examination Accommodation: Academic Documentation The College of Psychologists of Ontario Form to be completed in its entirety by an appropriate representative of the Student Support Services/Access Office of the university attended by the candidate. Documentation relevant to the request for accommodation submitted by the candidate should be attached to/submitted with this form and sent directly to the College at least 60 calendar days before the examination date. Please note that the College does not need to receive a diagnosis and that only personal and/or health information relevant to the candidate's need for and request for accommodation should be included. Please return by mail, e-mail or fax to: Myra Veluz, Senior Registration Assistant The College of Psychologists of Ontario 110 Eglinton Avenue West, Suite 500 Toronto, Ontario M4R 1A3 Tel: (416) 961 8817, Ext. 222; 1-800 489 8388, Ext. 222 E-mail: exams@cpo.on.ca Fax: (416) 961 2635 Candidate's full name (printed): Name of health professional (printed): Applicants to the College of Psychologists of Ontario are required to pass three entry-to-practice examinations as part of the registration process. 1. The Examination for Professional Practice in Psychology (EPPP) is a computer-based multiple-choice examination, which consists of 225 questions. Candidates are allowed four hours and 15 minutes to complete it. The EPPP is administered through an exam vendor, Pearson VUE on an on-going basis throughout the year at Pearson VUE testing sites in Canada and the United States. All candidates may have access to, and therefore do not have to request: - an adjustable armless chair; - adjustable font size; - ergonomic chair; and - ergonomic keyboard. 2. The Jurisprudence and Ethics Examination (JEE) is a two-hour written (paper and pencil) multiple-choice examination that consists of 60 questions. It is held at several examination centers in Ontario. 3. The Oral Examination: Once applicants have passed the EPPP and JEE and have met all the requirements, they will be invited to attempt the Oral Examination. The Oral Examination is a onehour in-person interview conducted by a team of three members of the College. Focused Interview Members of the College may be required to attend a focused interview if they are requesting changes to their certificate for registration. Such changes could include requesting a change or removal of a term, limit or condition and/or the expansion or addition of areas of competence. These one-hour interviews are conducted by a team of three members of the College, usually in an in-person setting. While the focused interview is not a formal examination, it is an assessment activity for which the College will provide accommodation consistent with the College s Examination Accommodation Policy. Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 13

1. Please describe the credential(s) which qualify you to diagnose and/or verify the candidate s disability or impairment and to recommend the testing accommodations: 2. Last date of contact with the candidate: 3. What is the nature of the disability or impairment that requires testing accommodations? (Please note that the College does not need to receive a specific diagnosis.) 4. What accommodations did the university make available to the candidate during their psychology degree program(s)? Please indicate whether this was at the Baccalaureate, Master s and/or Doctoral level. 5. How does the disability or impairment affect the candidate s ability to perform under the standard testing conditions as described for the EPPP, JEE and/or the Oral Examination and/or focused interview? 6. What accommodation(s) do you recommend the candidate request to mitigate the disability or impairment within the specific context of the College of Psychologists of Ontario s examination(s) and/or focused interview? I confirm that all the information on this form and any attached documentation is true and correct to the best of my knowledge and belief. I am aware that the information contained herein may be reviewed by a third-party such as a psycho-educational consultant in order to determine appropriate accommodations. I acknowledge that the personal information provided on this form is used by the College to administer the Regulated Health Professions Act, 1991, the Psychology Act, 1991 and its Regulations related to the governance of the psychology profession in Ontario. Information is collected, used, and disclosed in accordance with the College s Privacy Code. Name of the representative of Student Support Services/Access Office (print): Signature: Title: Address: E mail: Telephone number: License/Certificate Number (if a regulated professional): Date: Additional documentation of pages attached (number of pages): Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 14

F AUTHORIZATIONS F1 I authorize the College of Psychologists of Ontario to collect and maintain the information contained in this application and to obtain information from persons named in this application and from other persons or institutions as the College of Psychologists of Ontario in its discretion deems advisable in order to determine my eligibility for registration as a psychologist or psychological associate in the province of Ontario. I agree to save harmless all officers, directors, employees, servants and agents of the College of Psychologists of Ontario and those granting information regarding my application for registration at the request of the College of Psychologists of Ontario and hereby consent to the requesting and granting of any and all such information. I also authorize and consent to the release of any information obtained by the College of Psychologists of Ontario in the course of reviewing my application for registration at the request of any other professional body to whom I make application for registration, certification or licensing. F2 I certify that the statements made by me in this application are true, complete, and correct. I understand that a false statement may disqualify me from registration or be cause for revocation of any registration which may have been granted to me. Signed: Date: The College collects and uses the information in this application to assess whether you qualify to be issued with a certificate for autonomous practice as a psychologist or psychological associate in Ontario. The College discloses information only as permitted by Section 36 of the Regulated Health Professions Act, or as required by law. An application fee, which is non-refundable, is required for receipt and processing of your application. It is your responsibility to check with the College to ensure that all necessary documentation has been received. Applicants have 24 months from the date of application to submit all documentation required for issuance of a certificate of registration. G APPLICATION EXPIRY An application for registration that has not resulted in the issuance of a certificate of registration will automatically expire 24 months after the date of application (see Box A1 of this form). The application and any supporting documents will then be destroyed. Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 15

T H E C O L L E G E O F P S Y C H O L O G I S T S O F O N T A R I O L'O R D R E D E S P S Y C H O L O G U E S D E L O N T A R I O 110 Eglinton Avenue West, Suite 500, Toronto, Ontario M4R 1A3 Tel (416) 961-8817 Fax (416) 961-2635 email: cpo@cpo.on.ca To be completed by applicant REGISTRATION VERIFICATION FORM: PART 1 Submit your completed copy of Part 1 to each jurisdiction where you currently hold or have held a license to practise psychology along with a blank copy of Part 2. 1. Full Name of Applicant: 2. License/Registration/Certification #: 3. Province/Territory: 4. Are you currently or have you previously been disciplined by a regulatory body in any jurisdiction? No 5. Are there any outstanding complaints against you, which have been referred to a discipline or fitness hearing or to an alternative complaint resolution process which are currently under investigation? No 6. Has your license ever been subject to any terms, conditions, or limitations? No If you have answered yes to questions 4, 5, or 6, please attach additional information. I HEREBY authorize the release of information to The College of Psychologists of Ontario about: a) Information regarding my current or past registration in this jurisdiction; b) Any outstanding complaints against me that are currently under investigation or that have been referred either to a discipline or fitness hearing or to an alternative resolution process; and c) Current or prior orders of discipline to which I have been subjected Signature of Applicant Date of Signature Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 16

T H E C O L L E G E O F P S Y C H O L O G I S T S O F O N T A R I O L'O R D R E D E S P S Y C H O L O G U E S D E L O N T A R I O 110 Eglinton Avenue West, Suite 500, Toronto, Ontario M4R 1A3 Tel (416) 961-8817 Fax (416) 961-2635 email: cpo@cpo.on.ca REGISTRATION VERIFICATION FORM: PART 2 To be complete by and authorized Official of the Regulatory Body and returned directly to the College of psychologists of Ontario 1. Full Name of Applicant: 2. License/Registration/Certification #: 3. Province/Territory: 4. Current Registration Status: 5. Date of Initial Registration: 6. Date of Expiration: 7. Has the applicant s registration been continuous since date of initial registration? No (If No, please attach additional information) 8. Please indicate the highest degree in psychology on which the applicant s registration in your jurisdiction was based upon: Institution Degree awarded (e.g. M.A., Ph.D.) Year degree awarded Name of program (e.g. clinical psychology) 9. For jurisdictions with reserved acts or actions, has this applicant been granted access to any reserved acts (e.g. diagnosis)? No If please specify: If applicant has been denied such access, please attach additional information. Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 17

10. Please indicate the areas of practice and client populations for which this applicant is authorized to provide psychological services in your jurisdiction (e.g. clinical psychology with adults): 11. Does the applicant have: a) Any current or previous conditions, terms, or limitations on his/her practice? No b) Any unresolved complaints concerning misconduct, incompetence, or incapacity? No c) Any complaints referred to discipline or fitness hearing or alternative resolution? No d) Any sanctions or censures? No If you have answered to questions 11. a), b), c), or d), please attach additional information. Board Seal Verified by: (Signature of Official) Printed Name and Title Regulatory Board Date Signed Application for Certificate of Registration Authorizing Autonomous Practice (January 2017) PAGE 18