Verification of Training Completion

What is the best way to get a verification form completed and signed? This is the place. Please follow these steps for a seamless verification process. Please allow extra time for processing as the entire office is working remotely due to Covid-19 and we may need to make a special trip to UWMC to search our non-digital records.

  1. Fill out your form with as much information as you can, you might not have everything, just do your best. It is really helpful to provide your internship year dates and to provide the name that you were using at the time of your internship if it differs from your name.
  2. Please use Ty Lostutter, PhD, Training Director, as your contact for this form. He might not have been the director or supervisor at the time of your internship, but he is the director at this time and, typically, the person to sign off on the verification. Dr. Lostutter’s Psychologist License is PY 60238397, initial issuance was 01/15/2014.
  3. Send a digital copy of your form to and the program coordinator will print the form out, complete any remaining info, and prepare for Dr. Lostutter’s signature.
  4. Once the form is signed, it will be scanned and sent back to you unless otherwise requested. We are happy to send out hard copies or the original to the requesting agency if needed.
  5. SAMPLE Washington State Department of Health License Verification Request Form
  6. Most common items you need to know when completing your form:
    1. The official dates for our internship program are always July 1, XXXX through June 30, XXXX. The only exceptions are if you took a leave of absence during your internship in which case your end date may have been modified to complete the 2000-hour requirement.
    2. We certify that our interns have completed a total of 2000 hours. The certified hours are calculated at 50 weeks X 40 hours per week, with 2 weeks of leave/vacation taken.
      1. The minimum total amount of supervision hours should be 200+ hours or greater. This is based on a total of 4 hours of supervision per week X 50 weeks. Of those total hours of supervision 100+ should be individual supervision and the additional 100+ hours could include other forms of supervision including: group, clinical team meetings/clinical rounds in which you were discussing cases, or additional individual supervision.
      2. Direct clinical hours face to face is estimated at – 800-1,000 hours or more. This is based on an average of complete 5 clinical contact hours per day, 4.5 days per week for 50 weeks.
      3. Other training related activities including didactics, journal club, seminars, grand rounds, chart review, writing notes, and other training related activities are usually estimated at 450+ hours or more depending on training goals.
    3. Washington State Provider Licensure Look Up – if your form requires your supervisor’s license number, please use The Provider Credential Search site to locate and complete the Psychologist License of your individual supervisors