Application for Membership
Society of Clinical Psychology (Division 12) of the American Psychological Association
Please read membership qualifications on the reverse side. FULL APA MEMBERSHIP IS REQUIRED.
_______________________________________________________________
Name - Last First Middle APA Member No._______________________________________________________________
Address
_______________________________________________________________
City State Zip Telephone No._________________________ ____ _________________________________
State Licensures Held ABPP Diploma in Clinical Psy. #APA Fellow? Yes o No o_______________________________ ________________________________
Doctoral Deg. (Ph.D., Psy.D., Ed.D., etc.) Year Awarded Institution Granting Degree
_______________________________________________________________________
Department Granting Degree Major Field of Study(Clinical, Counseling, 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 on the reverse side of this page. 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 $40 US. To expedite your application, please include a check; or your
Visa/Mastercard No. __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ expires ___/___.
($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 may STOP HERE. Your application is complete.
-----------------------------------------------------------------------------------------------------------------------------------
All other applicants must furnish additional information. Please check the category under which you are applying and fill out the remainder of the form as indicated. Do not send dues with this application. Upon approval of your application, you will be billed by Division 12.
I am applying for membership under the following option: (B, C, or D, check one)
B.o 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.o 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.o 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? Yes o No o Month /Year
_______________________________________ ________________________
University Your Director of Clinical Training
_______________________________________________________________
Address of University City State Zip
Retraining was: Full-time o Part-time o Hours per week________ ___________________________________
Applicant's Primary Professor
INTERNSHIP Was the internship you completed APA approved at your time of completion? o yes o no
_____________________________________ Date: _________ to ________
Institution/Agency Name Month/Year
_______________________________________________________________
Address City State Zip
Average number hours worked per week _________ Total number hours completed for internship _________
Your internship title ___________________________Describe 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
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.
Signed ____________________________________________________________ Date _________________