Department of Psychology

Department of Psychology Psychology Summer Enrichment Program Program Dates: May 19- June 27, 2014 Please send application, letters of recommendation and transcripts to: University of Detroit Mercy Doctoral Program in Clinical Psychology ATTN: Barry Dauphin, Ph.D. Director of Clinical Training 4001 W. McNichols Ave. Detroit, MI 48221 Instructions: Please type or print clearly in blue or black ink. Complete all sections of application. Official transcripts of all college level course work should be mailed to us directly from your institution. Return the application to the address at the end of the application no later than March 3, 2014. PROGRAM QUALIFICATIONS Be a U.S. citizen or U.S. national with appropriate documentation Have completed at least 2 years of college as demonstrated on official transcript Demonstrate an interest in pursuing a graduate degree in the Behavioral Health field such as Clinical Psychology, Social Work, Counseling, etc. Self-identify with an economically disadvantaged status based upon financial guidelines provided in application, or educationally disadvantaged status based on the definitions outlined in the application APPLICANT INFORMATION Last Name: First: Middle: Date of Birth: / / SSN: - - Current Mailing Address: (I will be at this current address until: / / ) Street: City: State: Zip Code: Current Phone: ( ) - Email: P a g e 1

Permanent Mailing Address (where you can be reached after July 1, 2014) Street City State Zip Code Permanent Phone ( ) - CITIZENSHIP What city and state/country are you originally from? Citizenship: US Citizen Permanent Resident Alien # Non-Resident Alien If you are not a US citizen Proof of residency is required (i.e. driver s license, passport or immigration card) ACADEMIC INFORMATION List most recent colleges or universities you have attended: Name of current College/University: City State Zip Code Dates of attendance: What is your major? Total credit hours completed Cumulative grade point average (GPA) **Note: you must have at least a 2.75 to apply to PSEP ** 2. Name of previous college/university (if applicable) City State Zip Code Dates of attendance: Total credit hours completed Cumulative grade point average (GPA) You must complete following the courses to participate in the PSEP program: (please have transcripts sent to the address provided) 1 semester of Introduction to Psychology 1 semester of an additional Psychology course 1 semester of a Statistics course (preferred, not mandatory) 1 semester of college level Math (or equivalent) 1 semester of English Composition (or equivalent) P a g e 2

Please list all Psychology, Math, and English course(s) you have taken and/or are currently enrolled. Please include grade received and semester/term you took the course. If you are currently attending and/or are registered for the course, note In Progress in the grade received column. Please be advised that all program pre-requisites and must be fulfilled prior to the program in order to qualify for admission into PSEP. COURSE SEMESTER COMPLETED GRADE RECEIVED P a g e 3

FINANCIAL INFORMATION What is your parents combined income as reported in the federal income tax form 1040 or 1040A for the 2012 tax year? (Please enclose a copy) $ If you are an independent student, what is your income as reported in the federal income tax form 1040 or 1040A for the 2012 tax year? (Please enclose a copy) $ PARENT INFORMATION Father s / Guardian s Name: Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Did your father/guardian attend college? Yes No Please check the highest level of degree obtained: High School Associate Bachelor s Master s Doctoral Other Occupation: Employer: Mother s / Guardian Name Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Did your mother/guardian attend college? Yes No Please check the highest level of degree obtained: High School Associate Bachelor s Master s Doctoral Other Occupation: Employer: FAMILY INFORMATION How many siblings do you have? What is/are their age? Have any of them attended college? Yes No If yes, how many? Have any attended graduate school? Yes No If yes, how many? Do you have any relatives in the health profession? Yes No If so, in what specific fields? ETHNIC/RACIAL IDENTITY Please check one 1 = American Indian or Alaska Native 2 = Asian (Specify): 3 = Black or African American 4 = Hispanic or Latino (Specify): 5 = Native Hawaiian or other Pacific Islander 6 = White 7 = Unknown 8 = Other (Specify): Do you have any Physical Disabilities that necessitate specifically designed instructional materials or programs, modified physical facilities, or related services to enable full participation in and access to the program? Yes No If yes, specify: P a g e 4

GRE / APPLICATION INFORMATION Have you previously taken the Graduate Record Examinations (GRE)? No, anticipated test date: / / Yes, date taken: / / (List GRE score and a attach a copy of your score report) Do you plan to retake the GRE? Verbal Quantitative Analytic Psychology Subject Yes, anticipated test date: / / No N/A Have you taken a GRE review course? Yes. If yes, where? No When do you plan to apply to graduate school? EXTRACURRICULAR ACTIVITIES List any work experiences, extracurricular activities and volunteer experiences: You may list these on a separate piece of paper. P a g e 5

DISADVANTAGE STATEMENT Please check all that apply. Educationally Disadvantaged: an individual who comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school or allied health program; e.g., a person who is the first generation to attend and graduate from a 4-year College/University, limited upper level courses in high school. Economically Disadvantaged: an individual who comes from a family with an annual income at or below low-income thresholds according to family size. Economically disadvantaged status is based upon the following chart: LOW-INCOME LEVELS FOR 2012 Size of Your Family Income Level 1... $22,340 2... 30,260 3... 38,180 4... 46,100 5... 54,020 6... 61,940 7... 69,860 8... 77,780 STATEMENT OF DISADVANTAGED STATUS Please describe any special circumstances in your background that would be helpful in addressing why you qualify for disadvantaged status. IF NECESSARY, YOU MAY USE ADDITIONAL PAGES. PLEASE PLACE NAME ON EACH SHEET. I CERTIFY THAT THE INFORMATION SUBMITTED IN THIS APPLICATION IS COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE. I CERTIFY THAT I MEET ALL PROGRAM CRITERIA. SIGNATURE DATE P a g e 6

PERSONAL ESSAY 500 WORD MINIMUM IN THE SPACE BELOW TYPE AN ESSAY DESCRIBING YOUR INTERESTS IN PSYCHOLOGY, GOALS, MOTIVATION, BACKGROUND AND REASONS FOR WANTING TO PARTICIPATE IN THIS PROGRAM. PLEASE ADDRESS THE FOLLOWING QUESTIONS: 1. Why have you decided to pursue a career in the behavioral health profession? 2. What are your goals as a behavioral health professional? 3. Explain your desire to become a participant in the Psychology Summer Enrichment Program and why you would be a good candidate for the program. 4. Describe any experiences you ve had in a behavioral health field. 5. Describe personal life experiences with underserved and disadvantaged health issues, and how these have stimulated you to pursue training in the behavioral health profession. IF NECESSARY, YOU MAY USE ADDITIONAL PAGES. PLEASE PLACE NAME ON EACH SHEET. P a g e 7

REFERENCES: Please request three (3) letters of recommendation to be mailed directly to Dr. Dauphin from each person making the recommendation. Note: At least two letters should come from college level instructors and the third can come from an advisor/counselor/employer/instructor. List the names and titles of the people you have asked to complete the 3 recommendation forms you received with your application. Name Title Institution E-mail address Name Title Institution E-mail address Name Title Institution E-mail address RECRUITMENT INFORMATION How did you hear about our program? Ad Counselor Friend Website Other Please name the source/person: Source s Address: City: State: Zip What type of community are you from? Rural Suburban Urban P a g e 8

Have you ever participated in a behavioral health careers opportunity program, a summer enrichment program (with a behavioral health focus), or summer research program? No Yes. Please list the name of the program, the location and dates attended: VERIFICATION STATEMENT I certify that the above information is true, complete and correct to the best of my knowledge. I understand that falsifying or providing incorrect information may jeopardize my participation in this or future University of Detroit Mercy School Psychology Summer Enrichment Programs. Student Signature Date INFORMATION RELEASE To be completed by the student: I,, am applying for admission to University of Detroit Mercy Psychology Summer Enrichment Program. I am aware of the provisions of the Family Educational Rights and Privacy Act or other state of federal laws, regulations, or policies and hereby authorize the release of the requested information directly to University of Detroit Mercy Psychology Summer Enrichment Program (i.e. transcripts, letters of recommendation, etc.). I realize that I may not view some of the information requested, for example, letters of recommendation. I understand that University of Detroit Mercy Psychology Summer Enrichment Program will also maintain records of my performance in program activities. I agree to the release of this information to University of Detroit Mercy Psychology Summer Enrichment Program staff members and the U.S. Department of Health and Human Services. I UNDERSTAND THAT THIS PERMISSION MAY BE WITHDRAWN AT ANY TIME. THE UNIVERSITY OF DETROIT MERCY PSYCHOLOGY SUMMER ENRICHMENT PROGRAM IS GIVEN PERMISSION TO REPRODUCE FOR PUBLICATIONS AND INTERNET USE ANY PHOTOS TAKEN OF MYSELF OR MY CHILD AT PROGRAM FUNCTIONS. Student Signature Date Parent / Guardian Signature (If student is under age 18) Date University of Detroit Mercy Psychology Summer Enrichment Program does not discriminate on the basis of race, color, gender, national origin, age, religion, creed, disability, political belief, sexual orientation, gender expression, and veteran's status, marital or parental status. P a g e 9

CHECK LIST We must receive the following required information by March 3rd, 2014 at 5 pm for your application to be considered. Please read carefully: o A current resume or curriculum vitae o Official transcripts submitted by each institution you attended o A copy of income tax returns o GRE scores (if taken) o A 2-3 paragraph essay explaining your disadvantaged status and how you qualify for PSEP o A Personal Essay (500 word minimum) o 3 letters of recommendation submitted by the person making the recommendation Applications, transcripts and letters of recommendation can be mailed to: Psychology Summer Enrichment Program University of Detroit Mercy Doctoral Program in Clinical Psychology ATTN: Barry Dauphin, Ph.D. Director of Clinical Training 4001 W. McNichols Detroit, MI 48221 *Applications can be submitted electronically as well. P a g e 10