Download application form - Hartford Hospital

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
**.