APPIC Membership Application. PART I FACE SHEET RETURN TO: Connie Hercey APPIC-Suite G Street, NE Washington, DC 20002

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1 APPIC Membership Application PART I FACE SHEET RETURN TO: Connie Hercey APPIC-Suite G Street, NE Washington, DC Please check below if you are applying for Predoctoral or Postdoctoral Membership. _X_ Predoctoral Postdoctoral Agency Name The Guidance Center Department or Division Other Title (if needed) Mailing Address 500 Limit Street City, State Leavenworth, KS Zip+4, Country 66048, USA *APA Accreditation: Accredited Accredited, Inactive Accredited, on Probation _X Not Accredited *CPA Accreditation: Accredited Accredited, Inactive Accredited, On Probation _X Not Accredited * IF APA OR CPA ACCREDITED SUBMIT: - Directory Face Sheet - $ 250 Application Fee (Everyone) - Letter from APA/ CPA Accreditation Office Phone Write your fax, or in the column below the line at right if you don t want it published in the directory. To make sure we record your address properly, please write it in CAPS and put a slash through the zeros. Appear in Directory Not in Directory Fax X Training Director s DBARNUM@THEGUIDANCE-CTR.ORG Training Director s Phone If you have World Wide Web Access to your training brochure/application, list your www address here: Application Deadline (mo/day): 11/15 Program start date (mo/day): 7/1 Chief Psychologist: David D. Barnum, PhD (First name, MI, Last name, Degree, ABPP) Training Director: David D. Barnum, PhD (First name, MI, Last name, Degree, ABPP)

2 Only one name is allowed in the Directory for each Number of licensed doctoral psychologists on staff: 4 Number of intern slots next academic year: 2 No. Full time No. Part time Funded FT: 2 Half time: Unfunded FT: 0 Half time: 0 Stipends: $20,000 Full time: $20,000 Half time:xxx Fringe Benefits: Health Insurance Dental Insurance AFLAC Availability Vision Insurance Availability Paid Time Off 11 paid holidays per year (9 full day; 2 half day) Continuing education funds Continuing education days (5) Professional Liability Insurance Number of completed applications last year: 1 This program uses the APPIC Application for Psychology Internship (AAPI): (circle one) NO with Additions How does the intern applicant get brochure and application information: (select one preference from the options below) visit website, the program, telephone the program or send a letter with a request for the materials. What is the preferred method of contacting the program when the intern applicant has questions? to training director. CERTIFICATION: APPIC is not an accrediting agency. Programs that would like to include their membership in written materials may list their programs as APPIC member, but not as APPIC Accredited or APPIC Approved. APPIC membership indicates that a program meets all membership criteria and conforms to APPIC policies. I hereby certify that this psychology program is in conformity with all APPIC policies and guidelines. Signature of Training Director Date form completed PLEASE NOTE: Programs that submit membership applications for the fall membership cycle (with a September 30 application deadline) are now REQUIRED to register for and participate in the APPIC Match. Please see APPIC's policies on Match participation for non-member programs for more information.

3 PART II APPLICATION FORM Name of internship program: The Guidance Center Pre-doctoral Internship in Professional Psychology Name and degree of person completing form: David Barnum, PhD Phone number: address: Date of application: 1/30/2009 Applicants for membership in APPIC must meet all of the criteria below. Programs are reviewed for adherence to the criteria every three years. Internships that are accredited by the American Psychological Association (APA) and/or the Canadian Psychological Association (CPA) at the time of initial application are recognized as meeting APPIC doctoral membership criteria and are automatically approved by the APPIC Board. If your program is APA and/or CPA accredited: Please review the criteria listed below and certify your acknowledgment of these by signing here. Submit this form with your accreditation letter. As an APPIC member, your program will be expected to comply with these criteria at all times. Signature of Training Director If your program is not APA and/or CPA accredited: The APPIC Membership criteria are listed below. Following each criterion is a series of questions that will provide evidence as to how your program fulfills these membership criteria. Please provide complete answers and/or cite the page number(s) of supporting documents that you have provided (e.g., brochure, training handbook). Complete answers will help us to verify your adherence to these criteria and speed the application process. If space on this form is insufficient please use additional pages. 1. A psychology internship is an organized training program that, in contrast to supervised experience or on-the-job training, is designed to provide the intern with a planned, programmed sequence of training experiences. The primary focus and purpose is assuring breadth and quality of training. a. Please describe the overall goals of the training program. Provide clinical assessment of the psychological functioning of consumers, including the appropriate integration of formal psychological testing procedures. Identify, develop, and apply appropriate psychological interventions, based on empirical data from both scientistpractitioner and local clinical scientist models Work effectively with a multidisciplinary team of mental health service providers while clearly maintaining the role of psychologist on that team.

4 Expand and enhance understanding of, facility with, and application of Ethical Principles and Practice Guidelines of the American Psychological Association, as well as issues of diversity in the delivery of psychological services. Cultivate the intern s professional identity while assisting and supporting the identification of his or her particular professional interests b. Please describe how the training curriculum is designed to achieve these goals. Primary placement is in outpatient services clinic with rotations in recovery services, crisis services, and either Community Support Services (adults with severe mental illness) or Community Based Services (children and youth with severe emotional disturbances. Supervision is provided by two PHD supervisors for all case work, plus rotational supervisors who manage the program which houses the rotation. The initial phase of the internship year represents orientation to the CMHC and CMHC system in Kansas, initiation of clinical work, and initial training on initial assessments, diagnosis, risk assessment and management, ethical reasoning, and core elements of effective treatment. The middle phase of the year represents a working and honing phase as we add in more psychological assessment work, shift into more advanced training topics, implement live supervision, and support supervision of practicum students by interns. The final phase of the internship year is focused on encouraging more independent professional functioning within the supports provided by the internship faculty. c. Please describe the location in which training occurs. (If your program has multiple training sites, each of these should be described separately). All training occurs at The Guidance Center, a community mental health center that serves three rural counties in Kansas. All interns are based at our Leavenworth location, and may elect to participate in rotations in the more rural sites located in our other two counties. The Center is composed of a multidisciplinary, integrated treatment team of an entire range of mental health professionals and paraprofessionals. The mission of TGC is to provide quality care to the residents of our three county area, especially including those who have limited or no means to pay for their care and those affected by severe mental illness. TGC is part of a larger network in Kansas that works to minimize placement of those with severe illness outside of their home communities, even in the event of crises and exacerbated symptoms. 2. The internship agency has a clearly designated doctoral level staff psychologist who is responsible for the integrity and quality of the training program. This person is actively licensed, certified, or registered by the State Board of Examiners in the jurisdiction where the program exists, and is present at the training facility for a minimum of 20 hours a week. a. Name of Psychology Training Director David Barnum, PhD b. State or Province of licensure/registration Kansas c. License # 1109 d. Hours present at training agency per week: 40 + e. Please describe the duties of the Training Director 1) Directs and organizes the program and its resources 2) Responsible for the selection process for all students, including predoctoral interns 3) Monitors and evaluates program goals and activities 4) Documents and maintains interns training records. 5) Primary clinical and administrative supervisor for all interns. 3. The internship agency training staff consists of at least two full time equivalent (i.e. 80 hours/week) doctoral level psychologists who serve as primary supervisors and who are actively licensed, certified, or registered as a psychologist by the Board of Examiners in the jurisdiction where the program exists.

5 a. If your program consists of a single agency that provides training at a single site, please complete Table A for that site (enclosed at the end of this document). See Attached b. If your program is multi-site (a single agency with multiple training sites) or is a consortium (multiple agencies cooperating to provide training at multiple sites), please complete a copy of Table A for each site. N/A c. It is expected that interns receive supervision during the year from at least two different supervisors Each intern receives a primary and secondary clinical supervisor and divides their outpatient caseload between those two supervisors. They are welcome to select a third supervisor if they wish, but must maintain a minimum of two supervisors throughout the year. Additionally, interns receive supervision from rotation supervisors when working within a given service. 4. Intern supervision is provided by staff members of the internship agency or by qualified affiliates of that agency who carry clinical responsibility for the cases being supervised. Regularly scheduled individual supervision is provided by one or more doctoral level licensed psychologists, at a ratio of no less than one hour of supervision for every 20 internship hours. Supervision is provided with the specific intent of dealing with psychological services rendered directly by the intern. (For example, if the intern is full time at 40 hours/week, then you would provide 2 hours of supervision each week; if the intern if half-time at 20 hours/week, then you would provide 1 hour of supervision.) a. How many hours of regularly scheduled, individual supervision is provided to each intern? Minimum of 2 hours/week, with 1 3 additional hours of group supervision per week. b. Please indicate where this is documented in the intern brochure/website or other public program documents. Inside informational brochure; will be included in larger website page. c. How does the program demonstrate that the supervisor is clinically responsible for the cases under supervision? Supervisor review and cosignature on all clinical documentation, including progress notes, letters, reports, etc. The indication of supervision is also included on the informed consent to treatment that in includes the supervisor s name and credentials. 5. The internship provides training in a range of psychological assessment and intervention activities conducted directly with recipients of psychological services. a. Please describe how the program provides breadth of training in psychological assessment. Interns are trained then supervised in the administration, scoring, interpretation, and reporting of results for a variety of standard psychological instruments. Initial focus is training effective use of the clinical interview as a source of assessment information. As requests for evaluation are brought to the psychology team, individualized evaluation plans are developed to address the specific evaluation question. Interns will obtain experience with cognitive assessment, ADHD assessment protocols, projective testing (e.g., Rorschach), objective testing (e.g., MMPI II/MMPI II RF, MCMI III, MMPI A, etc), and specific checklists (e.g., BDI II, BAI, CDI, etc). As the opportunity arises, interns are also afforded the opportunity to participate in forensic evaluations conducted by senior psychologists with the full participate of the intern. b. Please describe how the program provides breadth of training in psychological intervention.

6 Interns provide a range of clinical services to a broad array of consumers, including individual, family, couples, and group therapies, consultation, supervision of practicum students, psychological testing, and participation in state and local efforts to enhance and coordinate psychological services. Additionally, rotations provide interns with exposure to a broad array of severity levels and service models, including crisis services, substance abuse treatment services, and service for adults and children with severe mental illness. c. Please describe the patient/client population(s) served. Predominantly European American individuals and family living in a largely rural setting. African American and Latino clients are the predominant non white ethnic groups represented, although due to the presence of a military base in our community, individual of a broad range of nationalities utilize the Center s services. We have a large population of individuals who qualify for Medicaid. We serve a broad range of communities members, including those with adequate financial means to those with no means, those struggling with adjustment to life issues to those struggling with severe mental illness, and those freely seeking treatment on their own to those ordered to attend treatment services by the Court or corrections. 6. At least 25% of trainees' time is in face-to-face psychological services to patients/clients. a. How many hours per week do full-time interns spend in face-to-face direct service delivery? Interns are expected to provide direct care for at least 50% of their time, totaling a minimum of 20 hours/week in direct care. b. How many hours per week do part-time interns spend in face-to-face direct service delivery (if applicable)? N/A 7. The internship must provide at least two hours per week in didactic activities such as case conferences, seminars, in-service training, or grand rounds. a. How many hours per week do interns spend in didactic activities? 2 8, depending upon the week. 8. Internship training is at post-clerkship, post-practicum, and post-externship level, and precedes the granting of the doctoral degree. a. Is the completion of formal coursework and practicum training required prior to the beginning of internship? / No b. Is your internship a pre-doctoral psychology training experience? / No 9. The internship agency has a minimum of two interns at the predoctoral level of training during any training year. These interns must be at least half-time (i.e., 20 hours per week). The minimum number of interns must be on site and in training at the time of the initial application for APPIC membership. a. How many pre-doctoral psychology interns do you currently have on-site and in training? One. We will be offering 2 slots for the year. b. Please list the names and academic programs of interns currently receiving training in your pre-doctoral internship training program. Do not list post-doctoral fellows, practicum students, or psychology externs.

7 Psychology Intern s name Institution Degree type Paula Harkins University of Missouri-Kansas City PhD Clinical 10. The internship level psychology trainees have a title such as "intern," "resident," "fellow," or other designation of trainee status. a. What title do your psychology internship trainees use in the work setting? Interns hold the title of Pre Doctoral Psychology Intern. 11. The internship agency has a written statement or brochure that provides a clear description of the nature of the training program, including the goals and content of the internship and clear expectations for quantity and quality of the trainee's work. It is made available to prospective interns. a. Please attach a current copy of the internship brochure (or other public documents) sent to prospective interns. See Attached. b. Please indicate the page number(s) on which the program goals are described. Inside brochure, center panel c. Please indicate the page number(s) on which the content of the internship training is described. Inside brochure, center and right panel d. Please indicate the page number(s) on which the program s expectations for intern performance are described. Outside brochure, left panel e. How is this document made available to applicants? The Internship brochure is available via e mail to the Director and on our website at ctr.org. f. Please indicate the page number on which the official number of hours for the internship is listed (i.e., 2000, 1500, etc.). Outside brochure, left panel 12. Internship programs have documented due process procedures that describe separately how programs deal with (1) concerns about intern performance, and (2) interns' concerns about training. These procedures include the steps of notice, hearing, and appeal, and are given to the interns at the beginning of the training period. a. Please indicate the page number(s) of the public document (internship brochure, training manual or web site) on which the program s due process procedures are described (including separate procedures for handling intern performance problems and intern grievances against the program). Posted on website under Predoctoral Internship heading. b. When and how are interns informed about these due process procedures?

8 It is provided in the training manual they receive their first day of internship, and reviewed with the Director of Training during their orientation meeting. 13. The internship experience (minimum 1500 hours) must be completed in no less than 9 months and no more than 24 months. a. How many hours are required to complete the internship? 2000 b. How many consecutive months in residence are required to complete the internship? 12 c. Note: 9 or 10 month programs are only acceptable for School Psychology Internships. 14. APPIC member programs are required to issue a certificate of internship completion, which includes the word "Psychology," to all interns who have successfully completed the program. a. Please attach a sample of the certificate awarded to interns at the successful completion of the internship. If the program chooses to designate a practice area or special emphasis area on the certificate (e.g., child clinical psychology, health psychology, forensic psychology), this designation should be entirely consistent with the type of training provided during internship See Attached 15. At least twice a year the internship program conducts formal written evaluations of each trainee's performance. a. How often do interns receive formal written evaluation during the internship year? Mid point and Final. A copy of each evaluation is submitted to the intern s graduate program, after having been reviewed with the intern, along with a letter from the Director of Training summarizing the intern s experiences and performance. b. Please submit a copy of the program s evaluation form, which specifically reflects the training goals of the internship program as described above in criterion #1. Evaluation forms provided by the interns graduate programs are not sufficient, as they do not necessarily pertain to the stated goals of the internship program. See Attached. 16. The program has the necessary financial resources to achieve its training goals and objectives. Intern stipends shall be reasonable, fair, and stated clearly in advance (fee splitting arrangements are not acceptable). Unfunded internship positions are allowable only in unusual and infrequent circumstances. What amount constitutes reasonable and fair? APPIC expects that your stipend will be close in comparison to others in your geographic region; this information can be found through the APPIC Membership Directory. a. What is the stipend paid to each intern at your site? $20,000 b If this is a consortium, are stipends across sites the same or different? If different, please list each site and associated stipend, and explain further.

9 N/A c. How does your stipend compare with others in your geographic region? Median d. If your internship stipend is less than what is average for your geographic region, please describe steps you have taken to secure reasonable funding, as well as your plan to obtain future funding in order to meet this criteria. N/A If your program is a single agency with one or multiple training sites, and if this is your initial application, please submit your responses to the above items, along with a completed, signed and dated APPIC Directory Face Sheet. Please use the following checklist to ensure that you submit the necessary materials: _N/A Application Table A for each training site Table B (if a multi-site agency) Training program handbook, internship brochure and/or website materials Didactic calendar Due process and intern grievance procedure Certificate of internship completion Directory Face Sheet (for initial applications only) $250 Application fee (for initial applications only) If your program is composed of multiple agencies that have joined resources to provide training, please continue by responding to the following additional items for Consortium Internship Training Programs. CONSORTIA: Introduction: A successful consortium program is one that overcomes geographic and governance barriers and is able to function as a unified entity. Its training staff and students interact frequently enough and intensively enough to form a coordinated, functionally interdependent training unit that effectively uses all available training resources and provides high quality training. In addition to meeting the APPIC membership criteria for single agency internship or postdoctoral programs, consortium programs must demonstrate evidence of the following:

10 17. A primary consortium director (or co-directors) must be present at one or more of the training facilities for at least 20 hours a week. a. Name of Consortium Training Director: b. State or province of licensure/registration: c. License # d. Hours present at training agency per week: e. Please describe the duties of the Consortium Training Director: 18. Each agency or site has at least one clearly designated, appropriately credentialed doctoral level staff psychologist who is responsible for the integrity and quality of training and present at the agency/site for a minimum of 20 hours per week. a. Please submit a completed copy of Table A for each site (enclosed at end of this document). Only include licensed psychology supervisors. b. Please submit a completed copy of Table B (enclosed at end of this document). 19. Regularly scheduled consortium-wide activities, including formal, didactic face-to-face contact among trainees at least monthly; ongoing informal contact among trainees across sites; and structured faculty meetings at least quarterly. a. Please attach the most recent annual calendar of didactics. The schedule should indicate the content, format, presenter, frequency, duration and location of these sessions. Didactic activities refers to actual training opportunities and should include training activities beyond Intern Case Presentations. The syllabus (with dates and topics) should be submitted with your initial or renewal application. b. How does the consortium ensure that these didactic sessions are accessible to all interns, regardless of training site? c. Please describe how trainees maintain ongoing, informal contact across sites. d. Please describe the nature and frequency of consortium faculty meetings. 20. A formal plan outlining the didactic activities and procedures provided in the training program. a. Please submit the most recent annual calendar of didactics, as requested in 19a above. 21. Assurance of trainee contact with more than one supervisor. a. Please describe how the consortium ensures that each intern has substantial training contact with more than one doctoral psychology supervisor.

11 22. A written consortia contractual agreement delineating: the nature and characteristics of the participating entities; the rationale for the consortia partnership; each partner's commitment to the training/education program, its philosophy, model, and goals; each partner's obligations regarding contributions and access to resources; each partner's adherence to central control and coordination of the training program; each partner's commitment to uniform administration and implementation of the program's training principles, policies, and procedures addressing trainee/student admission, financial support, training resource access, potential performance expectations, and evaluations (Guidelines and Principles for Accreditation of Programs in Professional Psychology; Committee on Accreditation of the American Psychological Association); and due process procedures including notice, hearing and appeal. a. Please attach a copy of the written, signed, and dated consortium contractual agreement between the facilities participating in the consortium. b. Please submit a current copy of the internship brochure (or other public documents) sent to prospective interns (as requested in 11a). c. Please indicate the page number(s) that describe the consortium goals and objectives that are applicable to all interns, regardless of training site. Please describe the administrative structure of the consortium, including the role of the Training Director, any on-site coordinators, and the training staff of the participating agencies.

12 Table A Listing of Clinical Supervisors and Credentials (include only licensed Psychologists) SITE (please complete separately for each site of multi-site setting): Name of Supervisor Highest Degree and Field David Barnum PhD KS, 1109 Joy Prichard PhD KS, 1658 Johnette Clark PhD KS, 1021 Jill Thorne PsyD KS, 1214 Donna Fisher LSCSW KS, 1956 Mike James LCP, CADCII KS, 909 Joe Thorne LSCSW KS, 4583 License (State/Province & #) Licensed to Practice Independently? Hours present on site/week (#) Hours/week in direct supervision (#) PRN Hours/week in ot training activities

13 APPIC Application Form, 06/01 Table B Listing of Agencies in Multi-Site Settings Name of Agency #of FT Interns on-site for the entire training year # of PT Interns on-site for the entire training year # of FT Interns on-site for only part of the training year (please specify the number of weeks/months) # of PT Interns on-site for only part of the training year (please specify the number of weeks/months)