Provisional Applicant Reference Form

Provisional Applicant Reference Form

Practice of Psychology in the Core Competency Areas
Directions for PROVISIONAL APPLICANTS:
- Complete Section 1 - Provisional Applicant Information and Section 2 - Referee Contact Information on the following pages. Do not fill in any information outside of those two sections.
- Once sections 1 and 2 have been completed, proceed to the final page of the form and submit. Once submitted, an electronic copy of this form will be automatically forwarded to your referee so they may provide their reference.
- Repeat this process for each of your three referees.
- NOTE: Two of the three required references must come from psychologists. One reference may be submitted by a professional who is a member of a health-related regulated profession, and who is registered with their regulator under a graduate degree (i.e. master's level RPN, registered MSW). If you have questions about acceptable referees, please contact the College office.
Directions for REFEREES:
- Proceed to Section 3 - Referee Registration Information and complete all relevant sections.
- Once section 3 has been completed, fill out Section 4 - Professional Relationship with Provisional Applicant and Section 5 - Assessment of Provisional Applicant's Knowledge and Skills in the Five Core Competency Areas. Note that all referees must provide information regarding the provisional applicant's knowledge and skill in the practice of psychology within the core competency areas included on this form.
- Please ensure that you can adequately speak to each of the psychological competencies. If you are unable to do so, your reference will likely not be accepted.
- Once complete, please sign and submit the form. This completed form will be shared with the Saskatchewan College of Psychologists and added to the provisional applicants' file.
- NOTE: If you are not a psychologist, you must possess a graduate degree in another health-regulated profession, and be a member of that health-regulatory body in order to provide a reference.

Section 1 - Provisional Applicant Information

To be filled out by the provisional applicant. All marked fields are required.
Provisional Applicant Name*
Address*

Street Address

Street Address Line 2

CityProvince/State

Postal/Zip CodeCountry
Provisional Applicant Email*
Contact # *
Provisional Applicant Signature*

Clear
Date*

MonthDayYear
Please input your referee's contact information on the following page, then proceed to the end of the form and submit. A copy of the electronic form will be forwarded to your referee for completion. Separate forms must be completed for each of your three references.

Thank you.

Section 2 - Referee Information

To be filled out by the provisional applicant. All marked fields are required.
Referee Name*
Title/Position*
Agency*
Referee Email Address*
Contact #
Section 3 - Referee Registration Information

A or B to be filled out by the referee only.
A. If the reference is being provided by a psychologist:

Registration/License/Certification # in the province/state of . Effective date
If the reference is being provided by a psychologist who is not registered, please provide further information here:
B. If the reference is being provided by a professional registered with another health-related regulatory body:
Do you have a graduate degree in a health-regulated profession?

YesNo
If yes, are you registered/licensed/certified with that profession's regulatory body?

YesNo
Registration/License/Certification # in the province/state of . Your highest held degree . Effective date

Section 4 - Professional Relationship with Provisional Applicant

To be filled out by the referee only. All fields are required.
Please select one:

Completed reference form to remain confidentialCompleted reference form may be made available to applicant
Applicant has been know to me for Years and/or Months from Date to Date .
Relationship to provisional applicant (e.g., agency supervisor, co-worker, practicum/internship supervisor, etc.):
Agency and position of provisional applicant for which you are providing a reference:
Estimated percentage of time the provisional applicant spent in the provision of psychological activities (both direct and indirect activities):
Brief summary of psychological activities in which the provisional applicant was engaged:
Responsibilities other than psychological services and estimated percentage of time for each responsibility:

Section 5 - Assessment of Provisional Applicant's Knowledge and Skills in the Five Core Competency Areas

To be filled out by the referee only. All fields are required.
Please comment on the provisional applicants' knowledge and skill with respect to the following core psychological competencies.
1. Interpersonal Relationships
Communicates effectively with:
Clientele:
Colleagues:
Supervisors:
Establishes and maintains rapport with:
Clientele:
Colleagues:
Supervisors:
Establishes trust and respect within the professional relationship:
Has positive relationships with colleagues and peers, as well as appropriate interdisciplinary relationships with colleagues:
Establishes and maintains professional relationships with clients from all populations served:

2. Assessment and Evaluation
Psychological assessment and evaluation:
Demonstration of an understanding which leads to a practical plan of action:
Diagnositic classification (please comment only if you have an authorized endorsement to diagnose) or identification of strengths/competencies:
Diagnostic Classification:
Identification of strengths/competencies:
3. Intervention and Consultation
Offers psychological interventions that promote, restore, or enhance positive functioning and a sense of wellbeing in clients through preventive, developmental, and/or remedial services:
Selects appropriate intervention methods:
4. Research
Has an understanding of graduate-level research methods and the applications of scientific research, and ability to implement evidence-based research:
Has the ability to write professional reports:
5. Ethics and Standards
Accepts obligations, is sensitive to others, and conducts self in an ethical manner:
Establishes professional relationships within applicable constraints and standards:
Would you be willing to employ this provisional member within your organization:

YesNo
If no, please explain:
Referee Signature

Clear
Date Submitted

MonthDayYear
Saskatchewan College of Psychologists

1026 Winnipeg Street, Regina, SK S4R 8P8
Telephone: 306-352-1699/Fax: 306-352-1697
Email: skcp@sasktel.net
Website: www.skcp.ca
Should be Empty:

Provisional Applicant Reference Form

1. Interpersonal Relationships

2. Assessment and Evaluation

3. Intervention and Consultation

4. Research

5. Ethics and Standards