CLINICAL NEUROPSYCHOLOGY POST-DOCTORIAL FELLOWSHIP WAIANAE COAST COMPREHENSIVE HEALTH CENTER. Name (Last, First, Middle Initial):

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1 CLINICAL NEUROPSYCHOLOGY POST-DOCTORIAL FELLOWSHIP WAIANAE COAST COMPREHENSIVE HEALTH CENTER Please complete the following application. Any missing information may result in your application not being processed in a timely manner. If you have any questions regarding requested information, please contact the Director of Training. Date of Application: / / Name (Last, First, Middle Initial): Address: City: State: Zip Code: Primary Contact Number: ( ) - Other Contact Number (Circle One): Cell/ Work/ Home ( ) - Address: INTERNSHIP Name of Internship Site: Address of Internship Site: City: State: Zip Code: Name of Director of Training (DOT): Permission to contact DOT (Circle one): YES NO Phone number of DOT: ( ) - Internship accredited (Circle Yes or No): APA/CPA Yes/No APPIC Yes/No

2 GRADUATE SCHOOL An official transcript will need to be provided to Waianae Coast Comprehensive Health Center. The transcript must be official and submitted in a sealed, unopened envelope or sent directly from applicant s graduate school. Date Diploma Conferred: Name of Graduate School: Address of Graduate School: Phone Number of Graduate School: ( ) - Grade Point Average (GPA): Name of Advisor: Phone Number of Advisor: ( ) - Permission to Contact Graduate School Advisor (Circle One): YES NO Graduate School APA Accredited (Circle One): YES NO Please provide a list of courses attended in graduate school that are associated with Clinical Neuropsychology. Please provide course title and name of instructor. Do not include courses that did not receive a passing grade. List Neuropsychology Classes Taken in Graduate School: 2

3 The following sections will pertain to practicum experiences completed during the course of graduate school. Please complete the following sections pertaining to Diagnostic practicum, Intervention practicum, and Advanced practicum (if applicable). DIAGNOSTIC PRACTICUM Name of Diagnostic Practicum site: Address of Practicum site: Phone Number of Practicum Site: ( ) - Name of Primary Supervisor: Phone Number of Primary Supervisor: ( ) - Permission to Contact Primary Supervisor (Circle One): YES NO Please provide a brief description of diagnostic practicum duties, especially those pertaining to neuropsychology: Please provide a brief description of experience with neuropsychology tests during diagnostic practicum: 3

4 INTERVENTION PRACTICUM Name of Intervention Practicum site: Address of Practicum site: Phone Number of Practicum Site: ( ) - Name of Primary Supervisor: Phone Number of Primary Supervisor: ( ) - Permission to Contact Primary Supervisor (Circle One): YES NO Please provide a brief description of intervention practicum duties, especially those pertaining to neuropsychology: Please provide a brief description of experience with neuropsychology tests during intervention practicum (if applicable): Please provide a brief description of interventions utilized during intervention practicum: 4

5 ADVANCED PRACTICUM Name of Advanced Practicum site: Address of Practicum site: Phone Number of Practicum Site: ( ) - Name of Primary Supervisor: Phone Number of Primary Supervisor: ( ) - Permission to Contact Primary Supervisor (Circle One): YES NO Please provide a brief description of advanced practicum duties, especially those pertaining to neuropsychology: Please provide a brief description of experience with neuropsychology tests during advanced practicum (if applicable): 5

6 ADVANCED PRACTICUM-ADDITIONAL Name of Advanced Practicum site: Address of Practicum site: Phone Number of Practicum Site: ( ) - Name of Primary Supervisor: Phone Number of Primary Supervisor: ( ) - Permission to Contact Primary Supervisor (Circle One): YES NO Please provide a brief description of advanced practicum duties, especially those pertaining to neuropsychology: Please provide a brief description of experience with neuropsychology tests during advanced practicum (if applicable): 6

7 The following section will pertain to experience in research, completed during the course of graduate school and/or other clinical settings. RESEARCH Please briefly describe previous experiences in research: Please briefly describe current interests in research: Please list any rewards or grants received: 7

8 Please review your application to ensure that all given information is correct to your knowledge. After completion of application, include official, sealed transcript, upon submission, unless transcript is being sent from the school. All applications missing information will not be processed until completed. All applications will be expected, complete with transcript, on February 1, I acknowledge that all the information included in this application is true to the best of my knowledge. I understand that any falsification of information will result in my application being rejected. Signature Date Print Name Thank you for your interest in our clinical neuropsychology post-doctorial fellowship, at Waianae Coast Comprehensive Health Center. We look forward to connecting with you in regards to your application. 8