Psychology Clinic
Change of Indirect Ownership Application Packet

A State license is required to operate a Psychology Clinic (PSYCH) in California. A PSYCH means a clinic which provides psychological advice, services, or treatment to patients, under the direction of a clinical psychologist as defined in Health and Safety Code (HSC) section 1316.5, and is operated by a tax-exempt nonprofit corporation which is supported and maintained in whole or in part by donations, bequests, gifts, grants, government funds, or contributions which may be in the form of money, goods, or services. In a psychology clinic, any charges to the patient shall be based on the patient’s ability to pay, utilizing a sliding fee scale. No corporation other than a nonprofit corporation, exempt from federal taxation under paragraph (3), subsection (c) of section 501 of the Internal Revenue Code of 1954, as amended, or a statutory successor thereof, shall operate a psychology clinic, pursuant to HSC section 1204.1.

To report a Change of Indirect Ownership, you must complete the required application packet. Refer to HSC sections 1200 through 1245 for information regarding licensure requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The provider instructions are a resource to guide you through the process. The provider checklist identifies the required forms and supporting documents needed to apply for licensing. The Sample Application Packet is a visual aid that displays a sample of the completed forms contained in the application packet.

Please refer to the following links to get started:

Application Packet Forms

Applicants must complete and submit the following forms in the application packet:

• HS 200 – Licensure and Certification Application (PDF)
• HS 215A – Applicant Individual Information (PDF)
• HS 309 – Administrative Organization (PDF)

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377