Application Form for Scrutiny Under Directive 2005/36/Ec

APPLICATION FORM FOR SCRUTINY UNDER DIRECTIVE 2005/36/EC

OF PROFESSIONAL QUALIFICATIONS IN

CLINICAL PSYCHOLOGY

PLEASE READ INFORMATION NOTE AND GUIDE CAREFULLY BEFORE COMPLETING THIS FORM

PLEASE TYPE AND SIGN THIS FORM

(hand written forms will not be accepted)

A. PERSONAL DETAILS

Surname: ______Title: ______

Previous surname, if any: ______

First name(s): ______

Date of birth: Day__ __ Month__ __ Year______

Address for correspondence: ______

Email address: ______

Contact telephone number: ______

Citizenship: ______

(please submit a witnessed copy photographic ID)

Residency:

if you are neither Swiss nor an EEA national[1], are you legally resident in Ireland?

YES □

NO □

(If yes, please submit a witnessed copy of:

(a) your certificate of registration issued by the Garda National Immigration Bureau and showing the immigration stamp; and

(b) passport endorsement.

(The period of permission shown in the certificate and the passport should match.))

Eligibility to practise in the country in which qualification was obtained

Are you eligible to practise as a psychologist in the country in which qualification was obtained? YES □ NO □

B. QUALIFICATIONS IN PSYCHOLOGY

Please list all your degrees and qualifications in psychology in chronological order, starting with the first.

Full title of the course as named by the degree awarding authority / Degree and grade obtained / Start date,
completion date,
date awarded
(month & year) / Type of study and assessment method / Name of university, institute, college or other degree awarding authority / Name of accrediting body
Undergraduate
Undergraduate
Postgraduate
Postgraduate

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Notes about the row headings.

Full title of the course: Please give the full title of your degree exactly as shown on the degree certificate, including such descriptions as Joint Honours or Combined Studies.

Degree and grade obtained: Please give the abbreviated title of your degree with your honours classification, for example, BA 2(1) Hons, MPsychSc, PhD

Type of study and assessment method: Full time/part time/distance learning, Show whether your degree involved course work, empirical research, or some combination, and how it was assessed for example:

Course work and examination

60% course and exam, 40% thesis

Research and thesis

Course work and continuous assessment

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C. UNDERGRADUATE QUALIFICATION IN PSYCHOLOGY

Indicate below how you see your education/training in psychology as meeting the requirements in relation to some or all of the following components. The components are in accord with the Psychological Society of Ireland (PsSI) Guidelines on the Accreditation of Courses Leading to a First Qualification in Psychology.

a. include only courses in psychology (generally courses presented in psychology departments or by suitably qualified psychologists);

b. indicate clearly which courses were taken at an advanced level; and

c. include cross-references to the supporting documentation you have submitted, e.g. the course code from your official transcripts

Component / Information from applicant / Transcript course
reference number
Biological Bases of Behaviour
Required component
Include areas such as: Neuropsychology, Physiological Psychology, Behaviour Analysis, and Animal Behaviour
Developmental Psychology
Required component
Include areas such as: Child Psychology, Adolescence, Adulthood & Ageing, and Lifespan Development.
Cognitive Psychology
Required Component
Include areas such as:
Perception, Memory, Thinking and
Artificial Intelligence
Social Psychology
Required Component
Include areas such as:
Group Behaviour, and Organisational Psychology

C. UNDERGRADUATE QUALIFICATION IN PSYCHOLOGY continued

Component / Information from applicant / Transcript course reference number
Personality and Individual Differences
Required component
Include areas such as:
Personality Theory, and psychoanalysis.
Research Methods
Essential component
Include areas such as: Research Design, Psychological Statistics, Qualitative Methods, and Survey Methods.
Research Project
Specify any independent research and name of supervisor
Applied Psychology
Include areas such as: Psychology of Disability and Rehabilitation, Educational, Clinical, Health, Industrial, and Forensic Psychology
Other Areas of Psychology
Include areas such as: History of Psychology, Environmental, Cross-cultural Psychology, Theories of Psychology, and Professional Ethics
Communication and Interpersonal Skills
Include areas such as: Interviewing Techniques, Social Skills Training, Small Group Processes.

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D. POSTGRADUATE QUALIFICATION IN CLINICAL PSYCHOLOGY

Full title of postgraduate training course:______From: ______to:______(insert month and year)

Year 1 _____weeks Year 2_____weeks Year 3_____weeks Year 4______weeks Year 5_____weeks.

Proportion of total course time allocated to clinical placement experience______%; to academic teaching______%

Please give details of supervised placements during your professional training course

Placement setting
(full name and address of each placement) / Age ranges / Dates from/to / Total Number of placement days / Frequency of supervision / Name & position of supervisor / Method of assessment
1. / Adult Mental Health
2. / Child and Adolescent Mental Health
3. / Intellectual Disability
4. / Specialist Placement
5.
6.

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1. PLACEMENTS DURING TRAINING

Please provide details, for each placement outlined on previous page(s), of supervised training experience and skill development in the areas of a) assessment, b) formulation, c) written & oral communication, d) therapeutic models used, e) indirect work, f) multi-disciplinary contact, g) intervention and h) evaluation.

Adult Mental Health

Child and Adolescent Mental Health

Intellectual Disability

Specialist Placement

2. RANGE OF PRESENTING PROBLEMS

Please describe the range of presenting problems encountered in each placement.

Placement type / Presenting problems
Adult Mental Health

Child and Adolescent

Mental Health

Intellectual Disability
Specialist Placement

3. THERAPEUTIC MODELS

What were the dominant therapeutic models taught and practised on your course?

______

4. ACADEMIC PROGRAMME

Please describe the main topic areas covered including client groups; presenting problems, assessment, formulation, intervention, research methods & statistics, service based issues, professional/ethical issues and social/cultural issues. Cross reference by giving the course number or code from your official transcripts.

Year 1

Year 2

Year 3

5. ACADEMIC ASSESSMENT

Please give details of the academic work you submitted during training (indicate whether each piece was a case study, essay, research project, presentation or written/oral exam, thesis).

Title of work / Description and approximate word count

6. THESIS

Applicant should supply the a) official abstract and b) a structured summary of the thesis of 250 to 400 words in length using the guidelines below.

Please provide:

· The thesis title, number of words, and date examined

· Names of examiners and degree for which the thesis was presented

· Objectives: State the objective of the research and the main hypotheses or questions addressed.

· Design: Describe the design specifying the number of groups studied, and the number of occasions on which data were collected from these groups.

· Methods: State if quantitative or qualitative methods were used. Specify the number and characteristicsof participants; the assessment instruments, psychological tests or special apparatus used; and the procedures followed during data collection.

· Results: Give the main results. Numerical data may be given briefly.

· Data analysis: State the way qualitative data were processed or the statistics used to analyse quantitative data.

· Conclusions: State the conclusions from the research and the implications of these for clinical practice, policy development and further research.

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7. EXPERIENCE OF TEACHING/TRAINING/GIVING PRESENTATIONS DURING TRAINING

Topic / Audience / Date

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E. SUPERVISED CLINICAL PSYCHOLOGY EXPERIENCE

It is recognised that training structures differ across countries. Work experience supervised by a clinical psychologist, gained after formal postgraduate training may be considered in meeting the requirements in regard to clinical placements.

Please give details of the work experience you have obtained under the supervision of a clinical psychologist. (If the spaces provided are insufficient please photocopy this page to accommodate additional information and attach the photocopied page to your application.)

Work experience
(name and address) / Client group
and age ranges / Dates from/to / Number of days / Frequency of supervision / Name and position of supervisor / Method of assessment
1.
2.
3.
4.

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1. PRESENTING PROBLEMS

Please describe the range of presenting problems encountered in each area of supervised work experience post qualification.

Supervised Work Experience / Presenting Problems/Age ranges
1.
2.
3.
4.

2. THERAPEUTIC MODELS

What were the dominant therapeutic models taught and practised during your supervised clinical experience?

______

3. EXPERIENCE OF TEACHING/TRAINING/GIVING PRESENTATIONS DURING SUPERVISED CLINICAL EXPERIENCE

Topic / Audience / Date

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F. EMPLOYMENT AS A PSYCHOLOGIST
(If shortfalls in your academic qualifications are identified, post-qualification professional experience of the applicant must be considered so it is important that you provide complete information on your post qualification work experience as a practising psychologist)
Job title / Service name/client group / Address / Dates from/to / Hours per week / Main duties

Note: Job title (or occupation): Indicate with a bracket or in some other way any appointments you have held (or hold) concurrently.

Dates from/to: Give month and year. It will be assumed that you are not working as a psychologist during any period not accounted for in your employment record.

(If the spaces provided are insufficient please photocopy this page to accommodate additional information and attach the photocopied page to your application.)

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G. ADDITIONAL INFORMATION

State here any other information you feel is needed to support your application.

H. REFEREES

The Minister for Health is the Competent Authority for the assessment of psychology qualifications and is advised by Psychological Society of Ireland (PsSI). Either body may seek verification of the information provided by the applicant in relation to either professional training or subsequent professional experience.

You should identify two (2) referees – one for each area and ask that they each complete (in typed script) and sign the form overleaf. Appropriate referees would include the course co-ordinator or supervisor(s) during your professional training or senior psychologist(s) from your current or most recent employment.

FOR COMPLETION BY REFEREE 1

THE DoH/PsSI RESERVES THE RIGHT TO CONTACT REFEREES DIRECTLY

The applicant is applying for recognition of professional qualifications in clinical psychology obtained outside of Ireland (Republic of Ireland) in order to work as a clinical psychologist in the health service in the Republic of Ireland.

The Department of Health and/or the PsSI may seek verification from you of the information provided by the applicant in relation to either professional training or subsequent professional experience.

Please complete in typed script and then sign and stamp.

1. Name: ______

2. Official job title/position:______

3. Work address: ______

______

4. Email address: ______

5. Telephone number: ______

6. Nature of contact during training/work experience/employment: ______

7. Referees should indicate their status within the psychological society of their own country:

Name of psychological society: ______

Status: ______

Signed: ______Date: ______

Stamp of institution/service

FOR COMPLETION BY REFEREE 2

THE DoH/PsSI RESERVES THE RIGHT TO CONTACT REFEREES DIRECTLY

The Department of Health and/or the PsSI may seek verification from you of the information provided by the applicant in relation to either professional training or subsequent professional experience.

Please complete in typed script and then sign and stamp.

1. Name: ______

2. Official job title/position:______

3. Work address: ______

______

4. Email address: ______

5. Telephone number: ______

6. Nature of contact during training/work experience/employment: ______

7. Referees should indicate their status within the psychological society of their own country:

Name of Psychological Society: ______

Status: ______

Signed: ______Date: ______

Stamp of institution/service

I. EVIDENCE OF QUALIFICATION

Please list below the evidence you have enclosed which shows that your qualifications entitle you to practice as a psychologist in the country in which your qualification was obtained. If your registration or licence specifies an area of practice, for example, Clinical Psychology, please include this.

Please label each supporting document clearly

J. DECLARATION

Any recognition granted on the basis of fraudulent or falsified information, material misrepresentation or misstatement designed to mislead shall be invalid. The onus for ensuring the full and accurate disclosure of information rests with the applicant.

● I declare that the information given in this document and in all attached forms is true and accurate.

● I declare that I have not made a previous application for validation/recognition as a psychologist in Ireland

· I declare that I am eligible to practise as a psychologist in my home country.

● I declare that I have not been found guilty by any statutory registration/licensing body or professional body having jurisdiction in the matter of any professional misconduct within the scope of my profession as a psychologist resulting in the imposition of any suspension, fine, penalty or disciplinary measure.

● I declare that, subject to my qualifications being recognised, I am fit to practise as a psychologist in Ireland.