| _________________________________________________ |
____________________ |
| Name: Last, First Middle |
APA Member No. |
| _________________________________________________ |
|
| Street Address |
|
| _________________________________________________ |
____________________ |
| City, ST Zipcode |
Telephone No. |
| _________________________________________________ |
____________________ |
| State Licensures Held |
ABPP Diploma in
Clinical Psy. #. |
| APA Fellow? Yes No
|
|
| _________________________________________________ |
_________________________ |
| Doctoral Degree (Ph.D., Psy.D.,
Ed.D., etc.) Year Awarded |
Institution Granting
Degree |
| _________________________________________________ |
_________________________ |
| Department Granting Degree |
Major Field of Study
(Clinical, School, etc.) |
| _________________________________________________ |
|
| Title of Dissertation |
|
| A. I affirm that I
have a degree and internship in Clinical Psychology from an
APA approved or regionally accredited doctoral program which
qualifies me for membership under paragraph A of the membership
qualifications. The statements made in this application correctly
represent my qualifications for election to membership, and
I understand that if they do not, my membership may be voided.
Signed:___________________________________________________________
Date: ______________________________
Annual Assessment is US$60. To
expedite your application, please include a check, or your
VISA/Mastercard number.
VISA/MC No.:_____________________________________________________
Expiration Date:_______________________
($22.50 of assessment is for
subscription to Clinical Psychology: Science and Practice)
Applicants with doctoral degrees in clinical psychology
from APA-approved or regionally accredited programs my STOP
HERE. Your application is complete. All other applicants
please continue.
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All other applicants:
You are required to furnish additional information. Please
check the category under which you are applying and fill out
the remainder of the form as indicated. Don not send
dues with this application. Upon approval of your application,
you will be billed by Division 12.
I am applying for membership
under one of the following options: (circle one)
B. My doctoral degree was granted
in 1976 or later in another area of psychology, but I have
completed a formal retraining program in clinical
psychology which included both an academic and clinical
component and a formal internship equivalent to one
full-time year in duration. (Complete the Retraining, Internship
and Professional Experience sections.)
C. My doctoral degree was granted
before 1976 and in another area of psychology, but I have
been informally retrained in clinical psychology
(training included a formal internship equivalent
to one year in duration) and I have a history of
successful clinical practice. (Complete the Internship and
Professional Experience sections.)
D. My doctoral degree is not
in clinical psychology, but I have made substantial
research contributions to clinical psychology. (Complete
the Professional Experience section and include a Vita.)
Applicants with non-clinical
psychology degrees must complete appropriate section(s) below:
|
| ACADEMIC RETRAINING in Clinical Psychology |
Date: ____________to____________
|
| Retraining completed (circle one)?
Yes No |
|
| _________________________________________________ |
_________________________ |
| University |
Your Director of Clinical Training |
| _________________________________________________ |
|
| Address of University (City, ST
Zipcode) |
|
| Retraining was: Full-time o Part-time
o |
Hours per week________ |
| _________________________________________________ |
|
| Applicant's Primary Professor |
|
| |
|
| INTERNSHIP |
Date: ____________to____________
|
Was the internship you completed
APA approved at your time of completion?
o yes o no |
|
| _________________________________________________ |
|
| Institution/Agency Name |
|
| _________________________________________________ |
|
| Address (City, ST Zipcode) |
|
| Average number hours worked per
week: _________ |
Hours completed for internship:
________ |
| Your Internship Title:_____________________________________ |
|
| Briefly describe your internship
duties:___________________________________ |
|
| _________________________________________________ |
|
| Supervision: Complete
for each major supervisor(maximum of 3). Additional supervisors
may be listed on a separate sheet. |
| ___________________________________________________________________ |
| Internship Supervisor’s
Name
Highest degree earned
Licensure status |
| ___________________________________________________________________ |
| Internship
Supervisor’s Name
Highest degree earned
Licensure status |
| ___________________________________________________________________ |
| Internship Supervisor’s
Name
Highest degree earned
Licensure status |
| Approximate hours
of weekly supervision: individual supervision _________ group
supervision _________ |
| Describe supervision
____________________________________________________________________________________ |
| ____________________________________________________________________________ |
| PROFESSIONAL
EXPERIENCE |
|
| Please complete this
section for each period of employment. Additional pages may
be used or a curriculum vita may be submitted with Professional
Experience details. |
| ____________________________________________ |
Date: ____________ to __________ |
| Name of institution or agency
|
Month
and Year |
| ____________________________________________ |
___________________ |
| Address City |
State,Zip |
| __________________________________________ |
Hours worked per week: average
___ |
| Your Title |
|
| Describe the nature of your duties:
|
|
| _________________________________________________________________________________________________________________________ |
| _________________________________________________________________________________________________________________________ |
| I affirm that I have
read the Membership Qualifications for the Division of Clinical
Psychology and that the statements made in the application correctly
represent my qualifications for election to membership. I understand
that if they do not, my membership may be voided. |
| |