APPLICATION FOR THE POSTDOCTORAL RESIDENCY IN CLINICAL NEUROPSYCHOLOGY Hartford Hospital and The Institute of Living GENERAL INFORMATION Full name: Home address: E-Mail Address: Work address: Work/Home phone numbers: (Please indicate preference for mail and/or telephone contact). APPCN registrant number: The following items are to be arranged and sent by applicant. Applications will not be reviewed that are incomplete: 1. Curriculum vitae 2. Three professional letters of reference 3. Official Transcript of graduate training 4. Work samples: 2 Neuropsychological test reports (preferably with different supervisors) 1 Psychological test report 5. Completion of the postdoctoral application IN FULL. All application materials, letters of reference, and questions are to be directed to: Application for Neuropsychology Postdoctoral Fellowship c/o Denise Fogel, Psy.D., ABPP-CN Neuropsychology Postdoctoral Residency Director Hartford Hospital 80 Seymour St. Conklin Building, G1 Hartford, CT 06102 Phone (860) 545-2723 Fax (860) 545-5623 email: dfogel@harthosp.org IT IS EXPECTED THAT ALL DOCTORAL DEGREE REQUIREMENTS - INCLUDING DISSERTATION - BE COMPLETED PRIOR TO THE START OF THE POSTDOCTORAL FELLOWSHIP.
ACADEMIC EXPERIENCE 1. Name, address, and phone number of your doctoral program: 2. Name and phone number of your Graduate Training Director: 3. Program degree: Ph.D. Psy.D. 4. Is your program APA-approved? Yes No 5. Name, address, and phone number of your internship program: 6. Name and phone number of your Internship Training Director: 7. Is your internship program APA-approved? Yes No 8. Other undergraduate and/or graduate colleges attended: (List most recent first) Dates Degree 9. Title and Status of Dissertation (i.e., likely completion date): 10. List three faculty and internship supervisors (along with their phone numbers/contact information) who are familiar with your work from whom we may expect letters of recommendation. 2
GRADUATE COURSEWORK Please list GRADUATE courses (including course titles and grades) as well as other relevant didactic experiences you have had in the areas listed below. We expect that many of these areas may not have been covered in your graduate or internship training and will be part of your postdoctoral experience. These areas of learning form the core knowledge base that the Houston Conference Guidelines proposes for all clinical neuropsychologists. 1. Generic Psychology Core A. Statistics and methodology B. Learning, cognition and perception C. Social psychology and personality D. Biological basis of behavior E. Life span development F. History G. Cultural and individual differences and diversity 2. Generic Clinical Core A. Psychopathology B. Psychometric theory C. Interview and assessment techniques (including personality and cognitive assessment) D. Intervention techniques E. Professional ethics 3
3. Foundations for the study of brain-behavior relationships A. Functional neuroanatomy B. Neurological and related disorders including their etiology, pathology, course and treatment C. Non-neurologic conditions affecting CNS functioning D. Neuroimaging and other neurodiagnostic techniques E. Neurochemistry of behavior (e.g., psychopharmacology) F. Neuropsychology of behavior 4. Foundations for the practice of clinical neuropsychology A. Specialized neuropsychological assessment techniques B. Specialized neuropsychological intervention techniques C. Research design and analysis in neuropsychology D. Professional issues and ethics in neuropsychology E. Practical implications of neuropsychological conditions 4
THERAPY EXPERIENCE Please summarize experiences you have had conducting psychotherapy. Briefly describe populations and settings in which you have worked, diagnostic groups, theoretical paradigm, time frame, cultural issues, and whether you have conducted therapy in any languages other than English. This summary should be concise and is to serve as a broad overview of your therapy experience. ASSESSMENT EXPERIENCE Please summarize your experiences administering and interpreting neurocognitive and psychological test results. Be sure to address populations and settings, diagnoses, style (e.g., fixed vs flexible, quantitative vs process, etc.), cultural issues, and whether you are able to assess in languages other than English. Again, the purpose of this summary is to provide a broad overview of your assessment experience to date. PROFESSIONAL STATEMENT Please prepare and attach a professional statement that addresses the following: (a) why you chose the field of clinical neuropsychology, (b) your training goals for the fellowship, (c) your clinical orientations and/or areas of special interest in the field of clinical psychology, (d) research interests, (e) the strengths and limitations of the training that you have received up to this point in time, (f) your career goals and plans. Revised 09/08 5