Professional Regulation Commission
APPLICATION FOR PERMIT TO OPERATE
PSYCHOLOGY OR PSYCHOMETRIC OFFICE, CENTER, CLINIC OR FACILITY
INSTRUCTION:
This application must be accomplished by the applicant. Declaration of false statement is subject to administrative sanction and
criminal prosecution.
Initial RenewalGovernment Private Date Filed: _________________
Office Center Clinic Other Facility, please specify: __________________________
Part I. Personal Information:
NAME OF THE ORGANIZATION:
ADDRESS:
SEC Registration No./DTI Registration No./Charter (for BIR Certification of Registration No (for private entities).:
government Agencies):
Contact Number: E-Mail Address:
Head of the Psychological Service Unit or Facility: License No.:
Highest Educational Attainment of Facility Head: Years of experience as psychologist/psychometrician:
Years of experience in a supervisory capacity:
List of Human Complement (use separate sheet, if necessary):
Applicant:
NAME LICENSE NUMBER POST GRADUATE STUDIES (MA, MS or PhD) Completed
___________________________ __________________ _________________________________________
___________________________ __________________ _________________________________________
___________________________ __________________ _________________________________________
___________________________ __________________ _________________________________________
___________________________ __________________ _________________________________________
___________________________ __________________ _________________________________________
Other Support Staff:
NAME POSITION IN THE ORGANIZATION NAME POSITION IN THE ORGANIZATION
___________________________ ______________________ ________________________ ________________________
___________________________ ______________________ ________________________ ________________________
___________________________ ______________________ ________________________ ________________________
Part II Acknowledgement:
I HEREBY CERTIFY that the above information written by me are true and correct to the best of my knowledge and belief. I
further authorize the PRC and other agencies to investigate the authenticity of all documents presented.
I agree to the PRC Privacy Notice and give my consent to the collection and processing of my personal data in accordance
thereto.
_______________________________ ______________________
Signature over printed name Date
PART III Action Taken:
Regulation Division Legal Division (NCR) / Cashier – Finance and
Legal Officer – Office of the Regional Director Administrative Division
Processed by: (Verification whether there is a pending case against the head Amount: ________________
________________________ of the psychological service unit, psychologists, and O.R. No. ________________
psychometricians) Date: ________________
Date: ________________________
Issued by: ________________
Reviewed by:
__________________________________________________________
Chief, Regulation Division, Region ______
ACTION BY THE BOARD OF PSYCHOLOGY’S FOCAL PERSON
Approved Disapproved
______________________________________
Signature over Printed Name
Date : ________________________ Certificate No.: __________________
ACD-PSYCH-01
Rev. 00
July 26, 2023
Page 1 of 3
PROCEDURE THE ISSUANCE OF PERMIT TO OPERATE PSYCHOLOGY OR PSYCHOMETRIC OFFICE, CENTER, CLINIC
OR FACILITY
1. Secure Application Form at the Public Information Counter/Desk of the nearest PRC Office or download at www.prc.gov.ph;
2. Fill-out Application Form then proceed to Regional Office, Regulation Division for evaluation and assessment of supporting documents;
3. Proceed to the Legal Section/Division for the verification of the license of the head of PSU, psychologists and psychometricians whether
there is a pending case filed against them;
4. Proceed to Cash Section to pay the prescribed fee of P6,500.00;
5. Secure documentary stamps;
6. Submit the accomplished Application Form with proof of payment to Regulation Division;
7. Verify your application after _____ days from the time of submission.
CHECKLIST OF REQUIREMENTS
(Applications with incomplete documents will not be accepted)
FOR INITIAL AND RENEWAL OF ACCREDITATION
The application for the renewal of accreditation shall be filed at least three (3) months prior to the expiration of the accreditation
Government Agencies Private Entities
1) Photocopy of the Charter/Law/or equivalent document 1) Authenticated copy of the SEC Certificate of
establishing its existence; Registration/Authenticated copy of DTI Certificate of
2) Profile of the Psychology or Psychometrics office, Registration;
center, clinic or facility, with a brief statement of the 2) For SEC registered entities, authenticated copy of
nature of psychological services it provides, existing the Articles of Incorporated and By-laws;
staffing complement, among others; 3) Profile of the Psychology or Psychometrics office,
3) List of facilities, areas, furniture, assessment tools, center, clinic or facility, with a brief statement of the
including but not limited to test materials, nature of psychological services it provides, existing
questionnaires, reference manuals, etc. and other staffing complement, among others;
ancillary equipment necessary for the conduct of 4) List of facilities, areas, furniture, assessment tools,
competent and professional services; including but not limited to test materials,
4) Pictures of the secured storage area or room where questionnaires, reference manuals, etc. and other
psychometric and psychological materials and ancillary equipment necessary for the conduct of
questionnaires as well as other confidential materials competent and professional services;
are kept (The pictures submitted by the applicant shall 5) Pictures of the secured storage area or room where
be kept confidential and shall not be available for psychometric and psychological materials and
public viewing or inspection unless upon order of questionnaires as well as other confidential
competent authorities or with express written consent materials are kept (The pictures submitted by the
of the applicant); applicant shall be kept confidential and shall not be
5) Photocopy of the Diploma of the head of PSU for Post available for public viewing or inspection unless
Graduate studies (MA, MS or PhD in Psychology); upon order of competent authorities or with express
6) Transcript of Records of the head of PSU; written consent of the applicant);
7) Photocopies of Certificates of Relevant Training 6) Diploma of the head of PSU for Post Graduate
attended by the head of PSU for the last 3 years; studies (MA, MS or PhD in Psychology);
8) Notarized Contract of Employment of the head of PSU. 7) Transcript of Records of the head of PSU;
If the head of the PSU is the owner, this is not 8) Photocopies of Certificates of Relevant Training
required; attended by the head of PSU for the last 3 years;
9) For clinics or facilities attached or part of government 9) Notarized Contract of Employment of the head of
institution/agency, shall submit the photocopy of the PSU. If the head of the PSU is the owner, this is
charter of the entity to which they are attached or part not required;
of; 10) For clinics or facilities attached or part of a
10) For online psychotherapy or assessment, an school/university, church, hospital/health institution,
undertaking as to full accountability in ensuing data or corporate/ industrial firm shall submit the SEC or
security under the client’s confidentiality clause and DTI registration documents, whichever is applicable,
Data Privacy Law must be submitted; and of the entity to which they are attached or part of;
11) For online assessment, copyright usage of online 11) For online psychotherapy or assessment, an
assessment tools and proof of purchase must be undertaking as to full accountability in ensuing data
submitted. security under the client’s confidentiality clause and
Data Privacy Law must be submitted; and
12) For online assessment, copyright usage of online
assessment tools and proof of purchase must be
submitted.
ACD-PSYCH-01
Rev. 00
July 26, 2023
Page 2 of 3
ACD-PSYCH-01
Rev. 00
July 26, 2023
Page 3 of 3
