Request a Verification

If you need to verify credentials of multiple psychologists, please email amila@nationalregister.org.

Psychologist Information:
Name of National Register Member*
First Last
Name
First Last
Email of National Register Member*
Purpose of Verification*
If other, please specify*
Please send verification to:
Licensing Board*
State/Organization:*
Name of Contact at State/Organization*
First Last
Name of Contact at Licensing Board
First Last
Email of Contact at State/Organization*
Email of Contact at Licensing Board
How would you like the verification sent?*
Can we send verification via email?
- Yes
- No
Address for Hardcopy Mailing*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address for Email Copy*
Special Instructions
Who is submitting this request?*
Are you the Registrant or are you an employer, healthcare organization, etc., requesting to verify provider credentials?
- National Register member
- Employer, healthcare organization, other

Psychologist Information:

First	Last