[GPC FORM 1A]

PROFESSIONAL APPLICATION FORM

Upholding Standards, Protecting the People

IN COMPLIANCE WITH PART 5 OF THE HEALTH PROFESSIONALS REGULATORY

ACT, 2013 (ACT 857)

Please refer to the guidelines when completing this application Form

PERSONAL DETAILS

1. Name in full1 ……………………………………………………………………………………….……………………………………………….

Surname first name others
2
2. If married (woman), maiden name in full ……………………………………………………………………………………………
3. Postal Address……………………………………….............…………..……………………………...........................................
4. Residential Address………………………………………….…………………………………………………………............................
5. Email…………………………………….....………………………………….. Telephone……………………………............
6. Date of Birth……………………… Sex…………………………… Place of Birth…………………………………………………
7. Citizenship………………………………….. If Non Ghanaian, state country……………………………..………………
Duration in Ghana………………………………………………………………………………………………………………………..………
8. Category of Registration Seeking: Full ………………….………… Temporary ……………………………………..
9. Place of Practice…………………………………………………………………………………………………………………………………...
10. Sponsoring Agency………………………………………………………………………………………………………………………………..
Items 10 to be answered by those seeking Temporary Registration only

11. If you are or have been registered, certified or licensed as a professional psychologist or therapist by a
legal or professional Board in any country, give full details below, including name of Agency or Board,

1
Please attach full Curriculum Vitae
2
Attach Gazette copy of change of name

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date of original or certificate, specialty if designate and license or certificate number

……………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
12. Has any certificate or license granted to you ever been suspended or revoked? Yes/no.
If yes, please append details.

13. Have you ever had an application or registration, certification or licensing as a Psychologist rejected?
Yes/no. If yes, please append details.

14. Have you ever been convicted of any crime, or of professional misconduct or of consult unbecoming
to a psychologist? Yes/no. if yes, please append details.

15. Have you ever taken the “Examination or professional practice in psychology in any country? Yes/no.
If yes, on what date and which location? ...............................................................

(Please arrange for forwarding of your examination scores-See enclosed “Application Checklist”)

EDUCATION AND TRAINING

16. A. Colleges and Universities

Degree Date of
Institution Awarded Award_
1. …………..………………………………………………………………………………………………...................................................
2. ..……………………………………………………………………………………………………………………………………………..…….………
3. ……………………………………………………………………………………………………………………………………………………………..
4. ……………………………………………………………………………………………………………………………………………………………..
5. ……………………………………………………………………………………………………………………………………………………………..
6. …………………………………………………………………………………………………………………………………………………………….

B. Accreditation Status of Training Institution:…………………………………………….…………………………………….

Indicate the Accreditation Body………………………………………………………………………………………………………

C. Area of specialization in psychology/applied psychology at the graduate level:………………………………..

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D. Title of Master’s thesis ……………………………………………………..……………………………………………………..……..

………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………….………………………………………………….
Name of Supervisor… ...................................................................................Reference, if published
…………..…………………………………………………………………………………………………………………………………………..

E. Title of doctoral thesis

…………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………..

Name of Supervisor……………………………………………………………………………………………………………………..

Reference, if published………………………………………………………………………………………………………………...

Transcripts: Each applicant is required to submit to the Registrar ORIGINAL copies of transcripts of
the courses and certified copies of certificates for under graduate and graduate degrees, and full
address including email of each of the institutions.

F. List any post-graduate seminars or workshops attended and any other relevant training in the last
two years; with name, date, place and duration of workshop/training.
a. ………………………………………………………………………………………………………………………………………..
b. ………………………………………………………………………………………………………………………………………..
c. ………………………………………………………………………………………………………………………………………..
d. ………………………………………………………………………………………………………………………………………..
e. …………………………………………………………………………………………………………………………………………

PRACTICAL EXPERIENCE

PRACTICUM

17. Have you ever had any practicum? Yes/No If Yes, state date and time………………………………………..
a. Name of Facility/Institution of Practicum
b. Full address including email of facility…………………………………………………………..……………………….
……………………………………….……..……….……………………………………………………………………………………
c. Accreditation status of the Facility/Institution
d. Duration of Practicum (with dates) …………………………………………………….………………………………….

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e. Hours of Practical Sessions per Week…………………………..………………................................…………..

f. Field of Practice:………..………………………………………………………………………….……………………………..
g. Type of supervision received……………………….…………………………………………………….…………………..

INTERNSHIP

18. Have you ever had any Internship? Yes/No If Yes, state date and time…………………………………..
a. Field of Practice:…………………………………………………………………………………….……………………………..
b. Name of Facility/Institution of Internship
c. Accreditation status of the Facility/Institution
d. Full address including email of facility…………………………………………………………..……………………….
……………………………………….……..……….………………………………………………………………………………………
e. Duration of Internship3 (Portfolio) …………………………………………………….………………………………….
f. Hours of Practical Sessions per Week…………………………..………………................................…………..

g. Major Areas of Practice4 (Log Book):………………………………………….…………..……………………………..

………….…………………………….………………………………………………………………………….………………………..
h. Type of supervision received……………………….…………………………………………………….…………………..

i. Supervisor’s Affiliation (Licensure Status)………………………………………………………………………………

EMPLOYMENT (PROFESSIONAL WORK EXPERIENCE)

19. Employment status. Starting with the most recent, give a complete record of your experience. Include
supervised attachment and indicate acquire training experience.
1. Present Employment ……………………………………………………………………………………………………………………
2. Date from……………………………………… Title or Position ……………………………………………………................
3. Organization or Institution…………………………………………………………………………………………………………...
4. Your duties……………………………………………………………………………………………………………………………………
5. ……………………………………………………………………………………………………………………………………………………..
6. General services offered……………………………………………………………………………………………………………….
7. Full-time / Part time: ….. If part-time, state number of hours you work per week………………………..

3
Please attach Portfolio
4
Please attach Log Book

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20. Licensure Examination Status:

Pass Failed Waived (Evidence)………………………………………………………………..

21. (a) In which area of applied psychology do you consider yourself working (Please select NOT more
than two (2) Indicate with a tick ×):
Clinical Educational Organizational/Industrial
Counseling Environmental School
Community Experimental Social
Developmental Forensic Special Education
Cognitive Health Pastoral Care & Counselling
Consumer Neuropsychology Sports
Psychometrics/Measurement & Evaluation Psychotherapy (please specify)

(b) In which activity:

Therapy/Counseling Research Teaching Others (please specify)……………………………………

22. In what language(s) are you competent to provide services? Please list in order of proficiency.
1)…………………………………………………… 3)…………………………………………………
2)…………………………………………………… 4)…………………………………………………

23. List the names, positions and addresses of one licensed senior psychologists (worked for not less than
10 years) who is well acquainted with you and your work and a senior civil/public servant or a
minister of religion, to whom you are sending the enclosed reference forms5:
Name Address Position
I. ……………………………………………………………………………………………………………………………………………..
II. ……………………………………………………………………………………………………………………………………………..
III. ……………………………………………………………………………………………………………………………………………..

24. I certify that the statements made by me in this application are complete and correct to the best of
my knowledge and belief.
Date ……………………………………………………………. Signature ……………………………………………………..

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Attach Completed Reference Form

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FOR SUPERVISORS ONLY

Name (Internship Coordinator)

Internship Coordinator’s Signature & stamp Date

Name of Facility for internship

Starting date: Ending date:

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FOR FURTHER INFORMATION CALL:

PHONE: 0542293014/0503027254/0246416527
EMAIL: [email protected]

FOR OTHER REGISTRATION FORMS PLEASE CHECK

WeBSIte: www.ghanapsychologycouncil.gov.gh
Completed Form and attached Document should be sent to:

THe REGISTRAR
ROOM 20, OLD MINISTRY Of
HEALTH OPPOSIte MINISTRIes Post
OFFICE MINISTRIes, AccRA, GHANA
GHANA POST GPS: GA-110-3586

BAnK DetAILS:
Fidelity Bank
Ghana Psychology Council
Ridge Towers, Accra,
Bank Account No. 1050031790015

OR

SHORT CODE (ALL NETWORKS)

*222*7270#

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[Note: please refer to the enclosed “Application Checklist” for a complete summary of documentation
requirements]

APPLICATION CHECKLIST

(For use by the applicant ONLY)

Submission of the following documents is to be arranged by the applicant. Please note that the Board
will not consider your application until all documents and the application fee have been received. If
you wish to check the status of your application, please contact the Registrar for the Ghana
Psychological Council.
All Applicants
1. Application form fully completed and signed.
2. Application fee of {GHS 575.00 for Nationals; and $575.00 for foreign trained } (non-
refundable and subject to change without prior notification)*
3. Reference from one psychologist who have been familiar with your work for at least one year,
and a senior public servant who is acquainted to you.

4. Certified copies of certificates & Original official transcripts of all undergraduate and graduate
degrees and full address of each of the institutions attended including email addresses should be
provided.
5. Full updated curriculum vitae & two (2) Passport size pictures (white background)
6. (a) Applicants who will still require a year of supervision or post-doctoral experience signed
supervisors’ agreement forms from your proposed primary and standby supervisors is required.

(b) Applicants requesting waiver of the Board’s supervision requirement two assessments by
professional colleagues of your supervised, post-doctoral experience are required.

Additional Requirements- If Applicable

7. If formal conferral of your master’s/doctoral degree has not taken place and therefore is not
indicated on the official doctoral transcript, the Council will require a statement from the
Registrar of the university where you earned your degree confirming that all requirements,
including successful defense of the thesis, have been completed. The statement must be
forwarded directly to the Council office from the university department. Copies submitted by the
applicant will not be acceptable.
8. Applicants residing outside Ghana should provide a statement of their reasons for seeking
registration in Ghana.

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9. Applicants certified or licensed elsewhere: The Council will require a statement directly from the
Board/Council which granted your certificate/ license confirming your registration.
10. Applications that have previously completed the Examination for Professional Practice in
Psychology/Therapy. The Council will require a report of your examination scores directly from:
(i) The Board/Council which administered in any country examination.
11. If Master’s/doctoral degree was received from an institution outside of Ghana. The applicant will

be required to submit an evaluation of the degree.

Masters/Doctoral degrees from institutions in any country: It is the responsibility of the applicant to
ascertain that the institution which conferred the degree program is regionally accredited. The Board is
unable to consider applications based on degrees from institutions which are not regionally accredited. Also,
doctoral programs must meet the “criteria for Doctoral Programs leading to registration as a psychologist in
Ghana. In addition, a doctoral degree based on a program of studies from an institution outside Ghana must
first be evaluated to determine if it is recognized. It is the responsibility of the applicant to arrange for this
evaluation prior to making application for registration. Evaluations may be obtained through the Ghana
Board of Examiners in psychology.
The applicant must provide a statement that he/ she is requesting this evaluation for the purposes of
applying for registration to the Ghana Psychology Council.

The following documents are required for evaluation purposes:

(a) Copies of all transcripts of degrees and diplomas. These should be in the original language.
English translations are required.
(b) A list of all professional experience including practicum and internships.
(c) Copies of gazette names required for all change of names

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FOR OFFICE USE ONLY

Form Received by Date

Checked by _______

Amount paid Receipt No

Signature of Officer Date

Verified by

*Officer’s Comments & Suggestion:

Signature of Officer Date

*Registrar’s Comments:

Approved: Yes/No Registration No:

Signature & Stamp Date

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