SHEPS CENTER DATA REQUEST FORM
NC Health Professions Data
Psychologist and Psychological Associate Data
Fill out this form, print, and fax it to:
NC Psychology Board
895 State Farm Road, Suite 101
Boone, NC 28607
Ms. Martha N. Storie, Executive Director
Phone: (828) 262-2258
Fax: (828) 265-8611

Attach a separate page describing the intended use for the labels/listing. Once approval has been received by the Sheps Center, you will be contacted with an estimated price and delivery date of the output. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 if you have questions or need additional information.

Requester's Name:
Business Name:
Address:
City, State & ZIP:
Telephone Number:
Fax Number:
Email Address:
Type of Organization: For-Profit (FP)     Non-Profit (NP)

Electronic Output Request Type: Check one or more
Name, address, specialty, county ($4.50/100 names: $100.00(NP)/$200(FP) minimum)
All data available ($7.00/100 names: $200.00(NP)/$300(FP) minimum)

Output format:
 Tab-delimited Comma-delimited Fixed Field
Other (please specify):

SELECTION CRITERIA (check all that apply):

Profession: Psychologist    Psychological Associate

Activity Status: Active   Inactive

Area Selection: In-state   Out-of-state
Specific counties:
Other (please specify)

Practice Setting:
Unknown
State or Local Government
Federal
Public School
Non-Governmental Health Care
Private/Group
Educational Institution
Business/Industry
Other

Primary Specialty: Clinical   School   Counseling   Other

Description of Request: List other details of your request in the box below.


What order do you want the output sorted in?

NOTICE: Data are provided by the NC Psychology Board as of October each year and compiled by the Sheps Center. Address changes are made only at the time of the annual update. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 for more detailed information regarding the Sheps Center files.

For NC Psychology Board Use Only:
Approved by:______________________________________________  Date:________

Note to Board: Please send this form with approval to the Sheps Center Data Coordinator:
Fax (919) 966-5764.

Updated 5/1/05