GUIDELINES FOR SUBMITTING AN INTERNSHIP APPLICATION TO THE PSYCHOLOGY DIVISION OF THE SIR MORTIMER B. DAVIS-JEWISH GENERAL HOSPITAL

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1 GUIDELINES FOR SUBMITTING AN INTERNSHIP APPLICATION TO THE PSYCHOLOGY DIVISION OF THE SIR MORTIMER B. DAVIS-JEWISH GENERAL HOSPITAL Please note that these guidelines apply to students applying for all types of internships, including summer practicum, stages, field placement, and predoctoral internship. 1. Application deadline: November 30, The application should be submitted to: (Please download the application for completion) Hélène Dymetryszyn, Ph.D. Co-director and Coordinator Internship Education and Clinical Training Psychology Division SMBD-Jewish General Hospital 4333 Cote Ste Catherine Road Montreal, Quebec H3T 1E4 3. Dr. Dymetryszyn may be reached via at 4. The application should include the following: (1 copy of each item is required) Covering letter indicating the student s plans and special interests, both in terms of research and clinical work. How do you see our internship site as meeting your training goals? Curriculum vitae A completed application form An official copy of graduate and undergraduate transcripts Three letters of reference. These letters may be included with the other application materials if they are in sealed envelopes, or can be forwarded directly by the referees. 5. Information and application forms are available on the web at For questions regarding administrative issues, please contact Johanne Archambault at 6. The application form is a modified version of the APPIC application for Psychology Internship (AAPI). The data requested are comprehensive, but we do not expect that an intern applicant would have had all the experiences listed, administered all of the assessment instruments, or be licensed as a mental health practitioner. The form is designed to be completed on a computer. (at-sign) character has been used to designate the places in which you need to enter information. Simply use your word processor to replace character with the appropriate information. Some questions will provide a list of answers, each preceded by and will instruct you to put an X next to one choice. To respond to these questions, replace next to your answer with an X, and change all symbols to blank spaces.

2 APPLICATION FOR PSYCHOLOGY INTERNSHIP Division of Psychology, Sir Mortimer B. Davis-Jewish General Hospital PART 1 Type of internship sought: Summer Practicum Field Placement Predoctoral Internship Full-time Part-time (specify ) Start date of internship: SECTION 1: BACKGROUND AND EDUCATIONAL INFORMATION A. BACKGROUND 1. Name: 2. Home Address: 3. Work Address: 4. Phone (Home): 5. Phone (Work): 6. FAX: PLEASE SPECIFY THE PHONE NUMBER WHERE YOU MAY BE REACHED ON APPIC MATCH DAY.

3 B. EDUCATION Current Academic Work 1. What is your university affiliation? 2. What is the name of your department? (e.g. Department of Psychology, Division of Behavioral Foundations in Educational Psychology)? 3. What is the designated subfield of your degree in Psychology? (Put an X next to only one choice): Clinical (adult track) Health Clinical (child track) Neuropsychology /Not available 2006/07 Clinical (general) School Counseling Respecialization Program Developmental Combined (Specify: Educational Other (Specify: 4. What degree are you seeking? (Put an X next to only one choice) Ph.D. Psy.D. Ed.D. Ph.D./J.D. Certificate/Respecialization (Specify: Other (Specify: 5. Name of Training Director: 6. Training Director 7. University / School Phone #: 8. University / School Fax #: 9. When did you begin graduate level study in your current program? / (mm / yyyy)

4 Previous Academic Work 10. Please complete the following table for each undergraduate school attended: (list in chronological order). Degree School / University Major Earned Dates of Attendance 11. Please complete the following table for each graduate school or university attended: (list in chronological order) Degree Dates of School / University Major Earned Attendance 12. Licensure / Certification: Some applicants may be licensed or certified at the master s level. If you are, please list any current and valid licenses or certifications in mental health fields (list type and jurisdiction, e.g., state or province): 13. Please list any honors received: 14. Please list names, addresses, phone numbers, and addresses of individuals who will be forwarding letters of recommendation:

5 SECTION 2: Clinical Experience This form was created to allow applicants to document their experience in therapy and other psychological interventions. While this form lists a wide range of experiences that one might have had, no applicant is expected to have experience in all, or even most, of these areas. INSTRUCTIONS FOR THIS SECTION: 1. You should only count hours for which you received formal academic training and credit or which were program-sanctioned training experiences. Practicum hours must be supervised. Please consult with your academic training director to determine whether experiences are considered program sanctioned or not. 2. Practicum hour - A practicum hour is a clock hour, not a semester / quarter hour. A minute client / patient hour may be counted as one practicum hour. 3. When calculating practicum hours, you should provide your best estimate of hours accrued or number of clients / patients seen. It is understood that you may not have the exact numbers available. Please round to the nearest whole number.

6 1. INTERVENTION AND ASSESSMENT EXPERIENCE - How much experience do you have with different types of psychological interventions and assessment? Please report actual clock hours in direct service to clients / patients. Hours should not be counted in more than one category. For the face-to-face columns, count each hour of a group, family, or couples session as one practicum hour. For example, a two-hour group session with 12 adults is counted as two hours. For the # of different... columns, count a couple, family, or group as one (1) unit. For example, meeting with a group of 12 adults over a ten-week period counts as one (1) group. Groups may be closed or open membership; but, in either case, count the group as one group. # of different a. Individual Therapy face-to-face individuals 1) Older Adults (65+) 2) Adults (18-64) 3) Adolescents (13-17) 4) School-Age (6-12) 5) Pre-School Age (3-5) 6) Infants / Toddlers (0-2) b. Career Counseling 1) Adults 2) Adolescents # of different c. Group Therapy face-to-face groups 1) Adults 2) Adolescents (13-17) 3) Children (12 and under) # of different d. Family Therapy face-to-face families

7 # of different e. Couples Therapy face-to-face couples f. School Counseling # of different Interventions face-to-face individuals 1) Consultation 2) Direct Intervention 3) Other (Specify) g. Other Psychological Interventions 1) Sports Psychology / Performance Enhancement 2) Medical / Health - Related Interventions 3) Intake Interview / Structured Interview 4) Substance Abuse Interventions 5) Other interventions (e.g., milieu therapy, treatment planning with the patient present.) Please describe the nature of the experience(s) listed in g-5:

8 h. Psychological Assessment Experience: This is the estimated total number of face to face client contact hours administering and providing feedback to clients/patients. 1) Psychodiagnostic test administration (Include symptom assessment, projectives, personality, objective measures, achievement, intelligence, and career assessment), and providing feedback to clients/patients. 2) 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). face-to-face i. Other Psychological Experience with Students and/or Organizations: 1) Supervision of other students performing intervention and assessment activities 2) Program Development/Outreach Programming 3) Outcome Assessment of programs or projects 4) Systems Intervention / Organizational Consultation / Performance Improvement 5) Other (Specify) face-to-face

9 2. TREATMENT SETTINGS - How many practicum hours have you spent in each of the following treatment settings? Please indicate the estimated total number of practicum hours (including intervention and assessment, support, and supervision) spent in each of the following treatment settings through November 1, Child Guidance Clinic Community Mental Health Centre Department Clinic (psychology clinic run by a department or school) Forensic / Justice setting (e.g., jail, prison) Inpatient Hospital Military Outpatient Medical / Psychiatric Clinic & Hospital University Counseling Center / Student Mental Health Center Schools Other (Specify) 3. In which languages other than English are you FLUENT enough to conduct therapy? 4. TEACHING EXPERIENCES - What is your teaching experience? Please summarize any teaching experience that you have. Include both undergraduate and graduate courses taught. 5. CLINICAL WORK EXPERIENCES What other clinical experiences have you had? Some students may have had work experience outside of their master s and doctoral training. This section is to include professional work experiences separate from practica or program sanctioned work experience. Use this section to describe settings and activities that are not included above. You may simply provide this information in narrative form or you may present this information in a format similar to that used above.

10 SECTION 3: TEST ADMINISTRATION 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 the number that you administered, scored, interpreted and wrote a report for in the second column. 1. ADULT TESTS # Administered # of Reports Name of Test and Scored Written 2. CHILD AND ADOLESCENT TESTS # Administered # of Reports Name of Test and Scored Written 3. INTEGRATED REPORT WRITING How many supervised integrated psychological reports have you written for each of the following populations? An integrated report includes a history, an interview, and at 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. a. Adults: b. Children / Adolescents:

11 Please select the service where you wish to undertake your internship. Consult our training brochure with respect to requirements before you make your choice. You may wish to apply for a combined internship (in two services), if so, please mark it down clearly below. Please mark your first and second choices, one of which, or both, may be combined internships. Inpatient Psychiatric Service [ ] Adult External Services: Cognitive Behavior Therapy Service [ ] Behavioral Medicine/Health Psychology [ ] Day Hospital [ ] Couple and Family Therapy [ ] Clinical Neuropsychology [ ] Youth Service (ages 16 20) [ ] Child Services: Day/Evening Hospital [ ] Outpatient Child Psychiatry [ ]

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