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Form 4 - Report of Professional Experience

This form must be submitted directly by the supervising psychologist who provided supervision of the professional experience claimed by the applicant. Please see instructions, also contained on the PDF form, for further information.

  • Section I: Complete this section and send the form and Instructions for Completing the Report of Professional Experience (Form 4) to your supervising psychologist. Be sure to sign and date item 7.
  • Section II and III: The supervising psychologist must complete these sections, sign and date the form and return it directly to the Office of the Professions at the mailing address on the form.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

  • OP can independently verify that the documentation is received directly from the supervisor
  • The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
  • Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.