Application for Clinical Practicum

Full Name

First

Last

Layout

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Graduate School:

Name of Degree Program (Psy.D. Ph.D. MA…)

Current Year of Graduate Study (first, second, third year…)

Do you speak Spanish or any other language; Please specify:

Coursework

From the list below, please choose courses you have taken:

Theories of Family Therapy
Multicultural/Cultural Diversity Course
Lifespan Development-particularly child/adolescent development
Ethics and Reporting Laws
Crisis Intervention & Trauma (including suicide assessment & intervention)
Other Intervention Courses (i.e. CBT, Psychodynamic)

Please Specify Name(s) of Course(s):

Clinical Interests & Experiences:

Provide brief answers to the questions below. If you are granted an interview, you will be asked to more fully discuss your answers.

1. Who and with what problems would you most like to work with clinically and how does this fit with your future career goals?

2. What has been the extent of your clinical experience thus far?

3. Do you have experience working with adolescents and or transition-aged youth?

4. Do you have experience working with life crises? (Assessment of depression, suicide, dangerousness, mediation, and verbal conflict)

5. Identify specific clinical theories of intervention that are appealing to you at this time:

6. What experience do you have working with people of color, specifically with African-American and other black people?

7. What do you know of Oakland’s community in terms of having knowledge about issues faced by youth and families?

8. What personal strengths and skills do you bring into your clinical work?

9. Do you have any other skills that might be helpful?

10. What are your training needs? What are you hoping to learn?

10. What are your training needs? What are you hoping to learn? (copy)

Time Availability

11. Are you available all-day Thursday?

Yes
No

12. What evenings (Mon-Thurs) are you available (up until 8:00PM)?

Monday
Tuesday
Wednesday
Thursday

13. Are you available for Saturday On-call? (The typical commitment of time is about one Saturday every five weeks)

Yes
No

14. What time limits or other restrictions should we discuss?

Please complete and submit this application along with:

Letter of recommendation

Click or drag a file to this area to upload.

Submit letter of recommendation from someone who knows your clinical work.

Curriculum Vitae.

Click or drag a file to this area to upload.

Cover Letter.

Click or drag a file to this area to upload.

Clinical Training Practicum

Coursework

Clinical Interests & Experiences:

Time Availability

Please complete and submit this application along with: