Internship Verification - Professional Licensing Boards

SUPERVISED INTERNSHIP EXPERIENCE VERIFICATION
This form may be duplicated for more than one supervisor.
WYOMING STATE BOARD OF PSYCHOLOGY
Emerson Building RM 104
2001 Capitol Avenue
Cheyenne, WY 82002
(307) 777-5403
The Board has received an application for a certificate from the applicant named below. The applicant has submitted your name
as a person who has supervised his/her professional experience. We would appreciate your providing the Board with the
information required and returning this form directly to the Board at the above address. This information will be kept confidential
by the Board, although the Board may inform the applicant as to whether the evaluation is generally favorable or unfavorable.
APPLICANT NAME:
LAST FIRST MI PREVIOUS NAMES (if any)
SUPERVISOR:
NAME
TITLE
ADDRESS: TELEPHONE: ( )
INTERNSHIP SITE:
ADDRESS: TELEPHONE: ( )
SUPERVISION:
Number of hours of supervision per full-time week:
Total hours of supervision:
Total hours of supervised work experience:
Dates of supervision: From To
MONTH/DAY/YEAR
MONTH/DAY/YEAR
Does the internship meet the current standards for graduate preparation approved by the National Association of School Psychologists
(NASP) Yes or No
Please describe the internship experiences in detail (types of clients seen, problem areas, and types of intervention used, etc.):
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SUPERVISED INTERNSHIP VERIFICATION
Evaluate the applicant on the following:
UNABLE TO
EVALUATE
NOT
ACCEPTABLE
AVERAGE
ABOVE
AVERAGE
SUPERIOR
A. Skill Level
B. Ability to establish and maintain good professional relations.
C. Possession of emotional maturity & stability required for
satisfactory work with clients and patients.
D. Understanding of and adherence to approved standards of
professional and ethical conduct.
E. Personal character: honesty, integrity and general conduct.
F. Reputation among colleagues as a professional.
G. Capacity for professional growth and development.
H. I would rate the applicant's performance under my supervision as:
I. I would rate the applicant's competence to engage in practice as a
specialist in school psychology as:
Remarks: Any additional information regarding your evaluation above would be appreciated. Please include any other
information you may consider to be relevant:
I hereby certify that the above information is fair and accurate. My judgement in this matter is based on:
personal records
my own knowledge
I recommend that the applicant be considered for licensing:
Without reservation
With reservation (please attach an explanation)
I do not recommend this applicant be considered for licensing (please attach an explanation)
Signature
Date
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