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APPLICATION FOR THE POSTDOCTORAL RESIDENCY IN CLINICAL PSYCHOLOGY The Institute of Living / Hartford Hospital General Information Full Name Home Address E-mail Address Work Address (h); Telephone Numbers (w); (c): APPCN Registrant Number* The following items are to be arranged and sent by the applicant. Applications that are incomplete will not be reviewed. 1. Curriculum vitae 2. Three (3) professional letters of reference. One letter should be provided from an internship supervisor. 3. An official graduate transcript 4. Work samples: For applicants to the neuropsychology and child/adolescent school-based areas of focus, 2 Neuropsychological or Psychological test reports (preferably from different supervisors), which must include a section addressing emotional/personality functioning. 5. A complete postdoctoral application form. Applicants are expected to have completed all doctoral degree requirements— including dissertation—prior to the start of the postdoctoral fellowship. All application materials, including letters of reference, and/or questions are to be directed to: The Institute of Living/Hartford Hospital ATTN: Paula Snedeker, AAIII Application for Postdoctoral Residency 200 Retreat Avenue Hartford, CT. 06106 Phone: (860) 545-7167 Fax: (860) 545-7222 E-mail: [email protected] *Neuropsychology applicants only ACADEMIC EXPERIENCE Doctoral Program Name: Address: Phone number: Graduate Training Director: Name: Phone number: Program degree: APA approved? Ph.D. Yes Psy.D. No Other? Please Specify: Internship Name: Address: Phone number: Internship Training Director: Name: Phone number: Internship APA approved? Yes No Dissertation Title: Status: Undergraduate & Graduate colleges attended (if other than Doctoral Program: Name Dates Degree GRADUATE COURSEWORK Please list all GRADUATE courses (including course titles and grades) as well as other relevant didactic experiences you have had in the following core areas. It is anticipated that many of these areas may not have been formally covered in your graduate and/or internship training and, as such, will be incorporated as part of your postdoctoral training experience. Sections III and IV are for Neuropsychology applicants only. These specific learning areas form the core knowledge base outlined by the Houston Conference Guidelines for specialized education and training in clinical neuropsychology. AREA I. General Psychology Core A. Statistics & Methodology B. Learning, Cognition & Perception C. Social Psychology & Personality D. Biological Basis of Behavior E. Life Span and Development F. History and Systems G. Cultural & Individual Differences & Diversity II. Generic Clinical Core A. Psychopathology B. Psychometric Theory C. Interview & Assessment Techniques (including personality & cognitive assessment) D. Intervention techniques, including: COURSE TITLE GRADE AREA COURSE TITLE * Group Psychotherapy * Family / Marital Psychotherapy * Cognitive Behavioral Approaches * Brief Therapy * Other E. Professional Ethics III. Foundations for the Study of Brain-Behavior Relationships A. Functional Neuroanatomy B. Neurological & Related Disorders, including etiology, pathology, course & treatment C. Non-Neurologic Conditions Affecting CNS Functioning D. Neuroimaging & Other Neurodiagnostic Techniques E. Neurochemistry of Behavior (e.g., psychopharmacology) F. Neuropsychology of Behavior IV. Foundations for the Practice of Clinical Neuropsychology A. Specialized Neuropsychological Assessment Techniques B. Specialized Neuropsychological Intervention Techniques C. Research Design & Analysis in Neuropsychology GRADE AREA COURSE TITLE GRADE D. Professional Issues and Ethics in Neuropsychology E. Practical Implications of Neuropsychological Conditions Please indicate the numbers of patients you have treated in PSYCHOTHERAPY according to the following diagnoses: (DO NOT INCLUDE PATIENTS SEEN AS PART OF TESTING). DISORDER Mood Disorders Psychotic Disorders Anxiety Disorders Somatoform Disorders Dissociative Disorders Sexual Disorders, Paraphilias & Gender Identity Disorders Substance-Related Disorders Dementias Borderline Personality Disorder Other Personality Disorders (specify): 1. 2. 3. Child Disorders: 1. Conduct Disorders 2. Developmental Disorders 3. Learning Disorders 4. ADD/ADHD 5. Other: INPATIENT OUTPATIENT Professional Statement Please prepare and attach a professional statement that addresses the following: Why did you chose the field of clinical psychology? What Area of Emphasis are applying to and What are your postdoctoral residency training goals? What is your clinical orientation and/or area of special interest in the field of clinical psychology? What are your experiences to date with regard to psychotherapy. What are your experiences to date with regard to assessment. What are your research interests? Discuss the strengths and limitations of the training that you have obtained up until this point in time. What are your long-term career goals and plans for the future? References Please list the contact information for the individuals who will be providing your letters of references. Note: One should be an internship supervisor. These individuals should be familiar with your work. Name: Title: Phone number: Address: Name: Title: Phone number: Address: Name: Title: Phone number: Address: Please indicate your familiarity with the following measures by checking the appropriate column. It is not expected that you will have administered and/or knowledge of all of these measures at the time of your postdoctoral fellowship. This is requested in order to obtain a sense of your overall testing experience. Applicants to the positions in the Anxiety Disorders Center do not need to fill out these sections Adult Tests TOMM Word Memory Test VIP WAIS-III WAIS-IV Stanford-Binet TONI-III Reynolds Intellectual Assessment Scale Dementia Rating Scale-II RBANS Delis-Kaplan Executive Function System Wisconsin Card Sorting Test Category Test Stroop Trail Making Test Color Trails Behavioral Dyscontrol Scale WMS-III WMS-IV CVLT-II Hopkins Verbal Learning Test Rey Osterreith Complex Figure Test Boston Naming Test Controlled Oral Word Association Test Peabody Picture Vocabulary Test Boston Diagnostic Aphasia Exam Judgment of Line Orientation Hooper Sensory Perceptual Exam Finger Tapping Hand Dynamometer (grip strength) Grooved Pegboard Geriatric Depression Scale BDI-II BAI Independently Administer Familiar With No Experience Adult Tests Personality Assessment Inventory (PAI) MMPI-II MCMI Rorschach Human Figure Drawings Other Projective Tests Thematic Apperception Test (TAT) Child and Adolescent Tests BASC Connors WISC-IV NEPSY-II Children's Memory Scale (CMS) WRAML-II CVLT-C WIAT-II Woodcock Johnson-Revised GORT-IV MAPI, MMPI-A Rorschach TAT, RATC Other Measures: Independently Administer Familiar With No Experience **.