APPLICATION FOR RENEWAL OF LICENSE

Dear Fellow Psychologist:

It is approaching the time that the Territory’s licensed psychologists need to renew credentials
before the December 31, 2020 deadline. Below are the documents needed to complete this
process:

Completed renewal application form
Application fee of $300.00 for Psychologists and $250.00 for Associate Psychologists
Proof of Continuing Education (certificates) indicating that you have satisfied the required 18 continuing education credit hours.
An updated Statement of Professional Intent and Professional Disclosure

To avoid $50.00 late fee, your renewal application needs to be submitted by December 15,
2020.

All payments must be made via PayPal

Sincerely,
Ramona Moss, Ph.D.
Ramona Moss, Ph.D., NCSP
Chairperson
V.I. Board of Psychology

Name *

Email *

MAILING ADDRESS: *

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Payment *

Signature

Are there any differences in your scope of practice? Are you providing a new type of service or services? Are you working with a new clientele?

Have there been any civil proceedings or sanctions from a licensing Board in another jurisdiction regarding your professional practice?

Have you been convicted of or entered a plea of guilty to any felony or misdemeanor charges other than a minor traffic violation?

STATEMENT OF PROFESSIONAL INTENT AND PROFESSIONAL DISCLOSURE STATEMENT

Under the Practice of Psychology section of the V.I. Code, section 169c(5) provides that each applicant for licensure declare areas of professional competence, and Section 1690 requires each licensed psychologist to display a Professional Disclosure Statement at the psychologist’s place of work.

Business Name *

Business Address *

Business number

State your formal professional education, including the institutions attended andthe degrees received.

Describe your intended use of the license.

For which client populations will you provide services?

State your theoretical orientation, areas of specialization and the services provided.

Provide your schedule listed by type of service or hourly rate

If you are a Psychological associate, provide your supervisor’s name, title, address and phone number.

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