Psychology Credentialing Request

Credentialing is required for anyone who is at the masters or doctoral level in psychology. When requesting credentialing for a new candidate, the requestor/supervisor/PI should complete the form below, which will be forwarded to Clinical Psychology department. Once received, the required registration documents and credentialing information will be sent to your candidate for completion. If you are requesting credentialing for multiple candidates, please submit a form for each one.

All fields marked with asterisk (*) are required.

Requestor's Information

Requestor Name

Requestor's Name cannot be empty

Requestor Email

Candidate's Information

First Name

Candidate's First Name cannot be empty

MiddleName

Last Name

Candidate's LastName cannot be empty

Additional Information

Entity:

NYS	RFMH
CU	Volunteer
NYP

Title

Title cannot be empty

PI/Faculty Supervisor

PI/Faculty Supervisor cannot be empty

PI/Faculty Supervisor Email

Reason for Request

For Exempt Status

For Clinical Privileges

Is candidate postdoctoral fellow or limited permit practitioner?

Yes

Will Candidate use HRO to submit documents?

Additional Notes/Comment