Previous-Clinical-Experience-Form1

Previous experience includes employment, clinical volunteering, practica, and internships.. Mark appropriate items with an X Couple Group Family Estimated number of hours of direct, fac

Please complete this form related to your previous clinical experience Previous experience includes

employment, clinical volunteering, practica, and internships

Have you had prior clinical experience?

(Highlight the correct cell)

Inclusive dates for all formal

TO graduate education

Total years of clinically relevant employment

Direct Service

Please indicate which modalities you have Individual

used (Mark appropriate items with an X) Couple

Group Family

Estimated number of hours of direct,

face-to-face intervention with clients

Estimated number of hours spent in direct,

face-to-face psychological assessment

Neuropsycholgical Tests

Rorschach TAT/CAT/SAT Projective Drawings

MMPI-2/MMPI-A/MMPI-2RF MCMI/MAPI

Supervision experience:

Estimated # of hours of one-to-one, face-to- Estimated # of hours of one-to-one, face-to-face supervision with a licensed psychologist face supervision with other licensed

received: professional (e.g., LCSW, LPC, LPA, MD)

group/peer supervision received:

Estimated number of hours of supervision Number of previous

Consultation experience:

Estimated number of hours of clinical

consultation provided to others:

Estimated number of hours of research

consultation provided to others:

Program development/evaluation:

Estimated number of hours of program

development/evaluation:

Prior Training Sites/Supervisors (please attach additional documentation if needed)

1 Site Name and Address:

2 Site Name and Address:

3 Site Name and Address:

Licenses currently held and in what state(s) Please attach a copy of all current licenses to your application

1 Type of License, Number,

and State:

2 Type of License, Number,

and State:

Have you had any previous complaints or disciplinary actions filed against you? Yes No

If yes, please explain (attach

additional documentation if

needed)

Current employment (if clinical in nature):

Site Name and Address:

Any clinical relevant volunteer activities:

Site Name and Address:

Please list any possible practicum training sites (within reasonable commuting distance) you are aware of: Site Name and Address:

Site Name and Address:

Site Name and Address:

Site Name and Address: