California State University, San Bernardino
APPLICATION TO SCHOOL PSYCHOLOGIST SERVICES CREDENTIAL PROGRAM
If accepted to this program, I will abide by the ethical principles as stipulated by the National Association of School Psychologist (NASP) and
the American Psychological Association (APA). Moreover, if admitted, I agree to join NASP as a student member and purchase liability
insurance.
Name:
______________________________
Signature:
___________________________
Address: _____________________________Birthdate: ___________________________
Social Security #: _____________________
City: ________________________________State: ___________ Zip: ______________
Work Phone:
Home Phone:
Gender: ___Male ___Female
Ethnicity:
Cell Phone:
Email:
Do you qualify as a person with disabilities under the Americans with Disabilities Act or Section 504 of the Rehabilitation Act?
Yes
No
Are you a Veteran?
___Yes ___No
Have you ever been convicted of a felony?
___Yes ___No
Are you currently being treated for any physical, emotional, or substance abuse disorder that might impair your ability to function as a school
psychologist?___Yes
___No
YEAR
INSTITUTION
BA/BS
______________________________________________________
MA/MS
______________________________________________________
PH.D./PSY.D.
______________________________________________________
Please list credentials or licenses:______________________________________________________________________
Which degrees have you obtained?
Number of years of teaching experience: _____ Number of years of counseling experience: _____
Please list bilingual skills: ________________________________________
Our program assumes that you have already successfully completed 450 hours of practica experience with students in preschool to twelfth grade settings.
The skills may entail roles such as counseling, consultation, assessment, program design, child study, prevention, intervention, etc... Please list your
previous experiences working with children or training for work with children. Estimate the number of hours you have participated in these activities.
Site/Setting
Estimated Hours
Experiences (e.g. Consultation, Counseling, Teaching, Assessment, etc...)




CCTC also stipulates that students must have some training in technology. Please list your technology expertise and/or training below (e.g. Microsoft
Word, Powerpoint, Library Search Engines, Excel, SPSSX, Corel, etc...).
Please attach a typed, 300 - 600 word personal statement addressing why you wish to become a school psychologist. Your statement should
address what personal and professional qualities you would bring to the practice of school psychology. Finally, your statement should list
and address what you believe to be the biggest issues facing school psychologists in today's public schools. You will be evaluated for writing
skills
California State University, San Bernardino
SCHOOL PSYCHOLOGIST CREDENTIAL PROGRAM
Professional Reference
Applicant: ___________________________________
The above named person is applying to the School Psychologist Credential Program. Please rate the applicant on the following
qualities or skills compared to other school psychologists or graduate students you have known.
Quality or Skill
Top 50%
Top 25%
Top 10%
Top 5%
Top 1%
1. W Writing Skills
2. V Verbal Skills
3. In Interpersonal Skills
4. Pr Professionalism
5. Pe Personal Integrity
6. Po Potential for Graduate Study
7. Cl Clinical Skills
8. C Commitment to Public Education
9. C Capacity to Work Independently
10.
Knowledge of Special Education Programs
11.
Computational Skills
12.
Cultural Competence
Evaluator's Name: ___________________________________
Evaluator's Position: _________________________
Date: ________
Please attach a letter detailing your knowledge of the applicant's work and potential to function as a school psychologist. Please
address the qualities or skills rated above paying particular attention to the applicant's verbal and written communication skills.
Completed rating form and letter of reference should be returned to:
Dr. Brett Nelson, Coordinator
School Psychology Program
Department of Educational Psychology and Counseling
California State University, San Bernardino
5500 University Parkway
San Bernardino, CA 92407-2397