Application for Board Certification in Pediatric Clinical Neuropsychology

APPLICATION FOR BOARD CERTIFICATION IN PEDIATRIC CLINICAL NEUROPSYCHOLOGY

A Subspecialty of the American Board of Clinical Neuropsychology

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Name: Click here to enter text.

Email: Click here to enter text.

1.  Have you passed the parent ABCN board certification process? ☐ YES ☐ NO

a.  If yes, please enter the date of your ABCN board certification (MM-YYYY): Click here to enter text.

b.  If no, skip to question 4 below.

2. Date of your doctoral degree: Click here to enter a date. (MM-YYYY)

3. Post-doctoral training program

a) Name: Click here to enter text.

b) Dates of post-doctoral training:

From: Click here to enter a date. (MM-YYYY)

To: Click here to enter a date. (MM-YYYY)

4. Post-doctoral and professional experience in pediatric neuropsychology. Note that “pediatric neuropsychology” experience is defined here as the provision of clinical neuropsychology services to patients aged 0-16 years.

All applicants must document a minimum of 4000 hours (i.e., 2 years full-time or equivalent on a part-time basis) of post-doctoral experience within pediatric neuropsychology as a trainee or independent professional.

Applicants who earned their doctoral degree or re-specialized in Clinical Neuropsychology prior to January 1, 2005: The required 4000 hours may have been completed during post-doctoral training (under the supervision of a pediatric neuropsychologist) and/or as an independent professional.

Applicants who earned their doctoral degree or re-specialized in Clinical Neuropsychology on or after January 1, 2005: Must document 4000 hours as noted above and document that at least 1000 of the required 4000 hours of pediatric neuropsychology experience was supervised by a pediatric neuropsychologist (e.g., completed during post-doctoral training under the supervision of a pediatric neuropsychologist). The remaining 3000 hours may have been completed as an independent professional.

a)  Estimate the total number of hours of professional experience devoted to pediatric neuropsychology practice, supervision and didactics (you may include both supervised and unsupervised experience in this estimate):

Click here to enter text.

b)  Estimate the number of hours of supervised post-doctoral training devoted to pediatric neuropsychology practice, supervision and didactics:

Click here to enter text.

c)  Professional Experience: Please describe your professional experience in pediatric neuropsychology beginning with your current position and including all prior positions.

Dates (MM-YYYY) / Full Time?
(Check One) / Position/Title / Institution / % Pediatric Neuropsychology Practice / Patient Populations
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
From: Click here to enter a date.
To: Click here to enter a date. / ☐ YES
☐ NO / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.

5. For your current position, what percentage of your time is spent in:

a) Pediatric neuropsychology clinical practice: Click here to enter text.

i)  Within your current clinical practice, what percentage of your time is spent with the following age groups:

0-6 years: Click here to enter text.

6-12 years: Click here to enter text.

12-16 years: Click here to enter text.

b) Pediatric neuropsychology research, scholarly writing, and/or clinical supervision/training: Click here to enter text.

c) If the majority of your professional time in the past 2 years was not in pediatric neuropsychology clinical practice, please provide information about your pediatric neuropsychology research, scholarly writing or clinical supervision/training and/or prior time periods in which the majority of your time was spent in pediatric neuropsychology clinical practice. Click here to enter text.

6. If you would like to clarify any of the professional experience information listed above, or if you need to list more experiences, please do so here: Click here to enter text.

7. Reference Letters: All applicants must submit two (2) letters of reference from health professionals verifying that the applicant has practiced pediatric neuropsychology for at least two years prior to application and accrued a minimum of 4000 hours of experience in pediatric neuropsychology over their professional career. It is preferred that at least one of the individuals writing letters have ABPP certification in Clinical Neuropsychology, Fellow status in the APA Society for Clinical Neuropsychology (Division 40), or demonstrated a similar degree of advanced knowledge, education, training, and practice in pediatric neuropsychology.

Applicants who earned their doctoral degree or re-specialized in Clinical Neuropsychology prior to January 1, 2005 must provide at least one letter from a pediatric neuropsychologist who is familiar with their work as a pediatric neuropsychologist.

Applicants who earned their doctoral degree or re-specialized in Clinical Neuropsychology on or after January 1, 2005 must provide one letter which attests that at least 1000 of the required 4000 hours were obtained under supervision of a neuropsychologist whose practice is primarily devoted to pediatric neuropsychology. Preferably, this letter will be obtained directly from the postdoctoral supervisor.

If for some reason you are unable to submit letters from persons who meet these criteria, please explain: Click here to enter text.

8. Curriculum Vitae: Please submit a current curriculum vitae documenting the dates, settings, and extent of the training, supervision, and clinical experiences described in your application.

9. Electronic signature & attestation. I hereby attest that in accordance with page 5 of the AMERICAN BOARD OF PROFESSIONAL PSYCHOLOGY AMERICAN BOARD OF CLINICAL NEUROPSYCHOLOGY CANDIDATE MANUAL: BOARD CERTIFICATION GUIDELINES AND PROCEDURES FOR THE SUBSPECIALTY OF PEDIATRIC CLINICAL NEUROPSYCHOLOGY, I have maintained a pediatric subspecialty practice in the two years prior to my application for this credential. I attest that the information provided herein is true and accurate to the best of my knowledge.

Name: Click here to enter text.

Date: Click here to enter a date.

Electronic submissions of this application form, CV and reference letters should be sent to the ABPP Central Office: