Psychology Practicum Application
Applicant Name
Preferred Mailing Address
2. Institution
First
Last
Home Address
Country
- None -AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSamoaSan MarinoSão Tomé & PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabwe
Business Address
Country
- None -AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSamoaSan MarinoSão Tomé & PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabwe
Home Phone
Cell Phone
Email
Email
Confirm Email
Program (e.g., Clinical or Counselling Psychology)
Level and year of program for upcoming practicum (e.g., MA2, PhD2)
Seeking Practicum Fall/Winter
Seeking Practicum Summer
Please rank in order of preference only those areas of interest
Outpatient Services
- None -1 (of high interest)2 (of moderate interest)3 (of lowest interest)
Includes: Outpatient General Adult Track, Borderline Personality Self-Regulation Clinic, The Traumatic Stress Clinic
Assessment & Reintegration Program - Inpatient General Adult Track
- None -1 (of high interest)2 (of moderate interest)3 (of lowest interest)
Adolescent Program
- None -1 (of high interest)2 (of moderate interest)3 (of lowest interest)
Forensic Outpatient Services
- None -1 (of high interest)2 (of moderate interest)3 (of lowest interest)
Forensic Inpatient Services
- None -1 (of high interest)2 (of moderate interest)3 (of lowest interest)
List below all the psychological assessment instruments you have experience in: administration, scoring, and interpretation.
Domain: Cognitive, Intellectual
Domain: Memory
Domain: Neuropsychological
Domain: Personality
Domain: Structured Clinical Interview
Domain: Symptom Rating Scales
Domain: Depression/Anxiety
Domain: Risk Assessment Forensic
Number Administered
Number of Tests Scored
Number Interpreted
Number Administered
Number of Tests Scored
Number of Tests Interpreted
Number Administered
Number Scored
Number Interpreted
Number Administered
Number Scored
Number Interpreted
Number Administered
Number Scored
Number Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Administered
Scored
Interpreted
Please list other tests that you have experience with that do not appear above
Other Test (A)
Other Test - A - Domain
Other Test - A - Test Name
Other Test - A - Administered
Other Test - A - Scored
Other Test - A - Interpreted
Other Test - B - Domain
Other Test - B - Test Name
Other Test - B - Administered
Other Test - B - Scored
Other Test - C - Interpreted
Please indicate the number of clients you have seen in each column according to treatment modality, individual versus group and length of treatment
Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
RC - Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
DBT_Number of Group Clients
Number of Individual Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
IP - Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
CCT - Number of Individual Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
Number of Group Clients
MCT - Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
FT - Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
EFT - Number of Individual Clients
Number of Group Clients
Number of Short-Term Sessions (< 13 sessions)
Number of Long-Term Sessions (> 12 sessions)
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adults
Adolescents
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
Children
Adolescents
Adults
Geriatrics
University
Date of Attendance
Major
Degree granted
APA/CPA Accredited
University
Date of Attendance
Major
Degree granted
APA/CPA Accredited
University
Date of Attendance
Major
Degree granted
APA/CPA Accredited
Location
Date Attended
Supervisor
Assessment
Therapy
Location
Date Attended
Supervisor
Assessment
Therapy
Location
Date Attended
Supervisor
Assessment
Therapy
Letters of Reference will be sent from the following (list two)
Reference #1: Name
Institution/Organization
Address
Telephone
Email
Reference #2: Name
Institution/Organization
Address
Telephone
Email