APPIC APPLICATION Summary of Practicum Experiences

Transcription

1 APPIC APPLICATION Summary of Practicum Experiences 1. Intervention Experience How much experience do you have with different types of psychological interventions? NOTE: Remember that hours accrued while earning a master s degree as part of a doctoral program should be counted as doctoral practicum hours. Please be advised that you don't have to enter 0 for hours. If you don t have any relevant experience, please leave this section blank. DOCTORAL TERMINAL MASTERS Individual Therapy Older Adults (65+) Adults (18-64) Adolescents (13-17) School-Age (6-12) Pre-School Age (3-5) Infants / Toddlers (0-2) Career Counselling Adults Adolescents (13-17) Group Counselling Groups Groups Adults Adolescents (13-17) Children (12 and under) Family Therapy Families Families Family Therapy Couples Therapy Couples Couples Couples Therapy 1

2 DOCTORAL TERMINAL MASTERS School Counselling Interventions Consultation Direct Intervention Other Other Psychological Interventions Sport Psychology / Performance Enhancement Medical / Health-Related Interventions Intake Interview / Structured Interview Substance Abuse Interventions Consultation Other Interventions (e.g., milieu therapy, treatment planning with the patient present) Please specify Other Interventions : Other Psychological Experience with Students and/or Organizations Supervision of other students performing intervention and assessment activities Program Development/Outreach Programming Outcome Assessment of programs or projects Systems Intervention / Organizational Consultation / Performance Improvement Other 2

3 2. Psychological Assessment Experience How much experience do you have with different types of psychological assessment? NOTE: Remember that hours accrued while earning a master s degree as part of a doctoral program should be counted as doctoral practicum hours. Please be advised that you don't have to enter 0 for hours. If you don t have any relevant experience, please leave this section blank. DOCTORAL TERMINAL MASTERS Psychological Assessment Experience Psychodiagnostic test administration (include symptom assessment, projectives, personality, objective measures, achievement, intelligence, and career assessment), and providing feedback to clients/patients. Neuropsychological Assessment (include intellectual assessment in this category only when it was administered in the context of neuropsychological assessment involving evaluation of multiple cognitive, sensory and motor functions). Other 3. Adult Assessment Instruments Symptom Inventories Beck Depression Inventory Hamilton Depression Scale Beck Anxiety Inventory Adult Manifest Anxiety Scaled Other s 3

4 Diagnostic Interview Protocols SADS SCID DIS General Cognitive Assessment Stanford-Binet 3 TONI-3 WAIS III and WAIS IV Visual-Motor Assessment Bender Gestalt Other Visual-Motor Assessment s Commonly Used Neuropsychological Assessment s Boston Diagnostic Aphasia Exam Brief Rating Scale of Executive Function Dementia Rating Scale - II California Verbal learning Test Continuous Performance Test Delis Kaplan Executive Function System Finger Tapping Grooved Pegboard Rey-Osterrieth Complex Figure 4

5 Commonly Used Neuropsychological Assessment s Trailmaking Test A & B Wechsler Memory Scale III Wisconsin Card Sorting Test Other s Commonly Used s of Academic Functioning Strong Interest Inventory Wechsler Individual Achievement Test (WIAT) Wide Range Assessment of Memory and Learning Woodcock Johnson-III (Achievement; Cognitive) WRAT-4 Other s Behavioral/Personality Inventories Millon Clinical Multi-Axial III (MCMI) Minnesota Multiphasic Personality Inventory Myers-Briggs Type Indicator Personality Assessment Inventory Other Inventories 5

6 s of Malingering Structured Interview of Reported Symptoms (SIRS) Miller Forensic Assessment of Symptoms Test (M- FAST) Rey 15-Item Test Test of Memory Malingering (TOMM) Other s Forensic/Risk Assessment Psychopathy Checklist- Revised (PCL-R); Static 99 Violence Risk Assessment Guide (VRAG) History-Clinical-Risk 20 (HCR-20) Validity Indicator Profile Other s Projective Assessment Human Figure Drawing Kinetic Family Drawing Sentence Completion Thematic Apperception Test Rorschach Other s 6

7 4. Integrated Reports An integrated report includes a history, an interview, and at least two tests from one or more of the following categories: personality assessments (objective, self-report, 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. Integrated Reports How many supervised integrated psychological reports have you written? 5. Supervision Received Supervised by a Licensed Psychologist: Supervised by a Licensed Allied Mental Health Professional: Other Supervision (e.g., supervision provided by an advanced graduate student who is supervised by licensed psychologist). Please specify type of license and mental health discipline of supervisor(s) in comment box below: Comments: (if any) DOCTORAL TOTAL HOURS TERMINAL MASTERS TOTAL HOURS Individual Group Individual Group TOTAL SUPERVISION HOURS individual Group Please indicate whether you have made audio or video recordings of your clinical work and reviewed them with your supervisor, as well as whether you have ever been directly observed by a supervisor: Audio Tape: YES NO Video Tape/Digital recording: YES NO Live/Direct observation by supervisor: YES NO 7

8 6. Additional Information About Practicum Experiences How many hours have you spent in each of the following treatment settings? INTERVENTION ASSESSMENT Doctoral Terminal Masters Total Hours Doctoral Terminal Masters Total Hours Child Guidance Clinic: Community Mental Health Center: Department Clinic (psychology clinic run by a department or school): Forensic / Justice setting (e.g., jail, prison): Medical Clinic / Hospital: VA Medical Center: Inpatient Psychiatric Hospital: Outpatient Psychiatric Clinic / Hospital: University Counseling Center / Student Mental Health Center: Schools: Other: 8

9 Have you led or co-led any type of groups? (Please describe the type of group, approximate duration and average number of clients at each group session.) Do you have experience with Managed Care Systems in a professional therapy / counselling / assessment capacity? YES NO What is your primary theoretical orientation? (Choose up to 3 and please rank order) Behavioural Biological Cognitive Behavioural Eclectic Humanistic/Existential Integrative Interpersonal Psychodynamic/Psychoanalytical Systems Other What is your practicum or program sanctioned work experience with diverse populations in a professional therapy / counselling or an assessment capacity? Please indicate the number of clients/patients seen for following each of the diverse populations. RACE African-American / Black / African Origin: Asian-American / Asian Origin / Pacific Islander: Latino-a / Hispanic: American Indian / Alaska Native / Aboriginal Canadian: European Origin / White: Bi-racial / Multi-racial: Other: Intervention Assessment SEXUAL ORIENTATION (Please indicate only when known) Heterosexual: Gay: Lesbian: Bisexual: Other: Intervention Assessment 9

10 What is your practicum or program sanctioned work experience with diverse populations in a professional therapy / counselling or an assessment capacity? Please indicate the number of clients/patients seen for following each of the diverse populations. DISABILITIES Physical / Orthopedic Disability: Blind / Visually Impaired: Deaf / Hard of Hearing: Learning / Cognitive Disability: Developmental Disability (Including Mental Retardation and Autism): Serious Mental Illness (e.g., primary psychotic disorders, major mood disorders that significantly interfere with adaptive functioning): Other: GENDER Intervention Assessment Male: Female: Transgender: Intervention Assessment 7. Support Activities Please indicate the primary activities in which you participated that comprise your support hour activities. If you think that your support hours include any activities that are unusual or unique to your program you can highlight that as well. Total Doctoral Support Hours: Total Terminal Master s Support Hours: 10

11 8. Practicum Hours Information PRACTICUM HOURS INFORMATION DOCTORAL HOURS TERMINAL MASTER HOURS Total Intervention Hours: Total Assessment Hours: Total Supervision Hours: 11