Other – (Specify e.g. Developmental, Specialty, Local Clinical Scientist)
When did you complete (or do you expect to complete) your doctoral coursework, including dissertation and internship hours (if applicable)?
Please list names, addresses, phone numbers, and e-mail addresses of individuals who will be forwarding letters of recommendation: (only 3 required)
SECTION 2: ESSAYS Instructions: Please answer each question in 500 words or less.
Please provide an autobiographical statement. (There is no “correct” format for this question. Answer this question as if someone had asked you; “tell me something about yourself.” It is an opportunity for you to provide the internship site with some information about yourself. It is entirely up to you to decide what information you wish to provide along with the format in which to present it.
Please describe your theoretical orientation and how this influences your approach to case conceptualization and intervention. You may use de-identified case material to illustrate your points if you choose.
INTERVENTION EXPERIENCE – How much experience do you have with different types of psychological interventions? Please check the patient contact you have had in each of the following areas:
Individual Therapy Older Adults (65+):
Pre-School Age (3-5):
Group Therapy Adults:
Children (12 and under):
INFORMATION ABOUT YOUR PRACTICUM AND WORK EXPERIENCE
TREATMENT SETTINGS –Please check the settings in which you have worked.
Child guidance Clinic:
Community Mental Health Center:
Department Clinic (psychology clinic run by a department or school):
Forensic/Justice setting (e.g., jail, prison):
Clinic & Hospital:
University Counseling Center/Student Mental Health Center:
Total Hours in all Treatment Settings:
What type of groups have you led or co-led? Please describe.
In which languages other than English (including American Sign Language), are you FLUENT enough to conduct therapy?
SECTION 4: TEST ADMINISTRATION What is your experience with the following instruments? Please indicate all instruments used by you in your assessment experience, excluding practice administrations to fellow students. You may include any experience you have had with these instruments such as work, research, practicum, etc., other than practice administrations. Please indicate the number of tests that you administered and scored in the first column and of these, please indicate in the second column, the number of reports that include an interpretation of this test. Please designate your experiences of the instruments listed below, without changing the sequence in which they are listed. Then, you may add as many additional lines (under “Other Tests”) as needed for any other test that you have administered.
How many supervised integrated psychological reports have you written for each of the following populations? An integrated report includes a history, an interview, and as least two tests from one or more of the following categories: personality assessments (objective and/or projective), intellectual assessment, cognitive assessment, and/or neuropsychological assessment. These are synthesized into a comprehensive report providing an overall picture of the patient/ client.
SECTION 5: PROFESSIONAL CONDUCT Please answer ALL of the following questions with “YES or “NO”: (If yes, please elaborate)
Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor, educational or training institution, health care institution, professional association, or licensing/certification board?
Are there any complaints currently pending against you before any of the above bodies?
Has there ever been a decision in a civil suit rendered against you relative to your professional work, or in any such action pending?
Have you ever been suspended, terminated or asked to resign by a graduate or internship training program, practicum site or employer?
Have you ever, in your lifetime, been convicted of an offense against the law other than a minor traffic violation?
Have you ever, in your lifetime, been convicted of a felony?
SECTION 6: APPLICATION VERTIFICATION I certify that all of the information submitted by me in this application is true to the best of my knowledge and belief. I understand that any significant misstatement in, or omission from, this application may be cause for denial of selection as a fellow or dismissal from a fellowship position. I authorize the training site to consult with persons and institutions with which I have been associated who may have information bearing on my professional competence, character and ethical qualifications now or in the future. I release from liability all fellowship staff for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I also release from liability all individuals and organizations who provide information to the fellowship site in good faith and without malice concerning my professional competence, ethics, character and other qualifications now or in the future. I authorize the fellowship site to consult with APPIC should the need arise.
If I am accepted and become a fellow, I expressly agree to comply full with the Association of Psychology Postdoctoral and Internship Centers (APPIC) policies, the Ethical Principles of Psychologists and Code of Conduct and the General Guidelines for Providers of Psychological Services of the American Psychological Association, and with the standards of the Canadian Psychological Association which are applicable. I also agree to comply with all applicable state, provincial and federal laws, all of the Rules and Code of Conduct of the state or Provincial Licensing Board of Psychology and the rules of the institution in which I am a fellow.
I understand and agree that, as an applicant for the psychology fellowship program, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications.