Midwestern University- Glendale
Clerkship Training Plan
Student: _____________________________________________________________________
Training Site: _________________________________________________________________
Training Start and End Dates: __________________ To____________________
Estimated Training Schedule (* See Supervisor Instructions):
Hours per week/days: ________________________________________
Total hours for the experience: __________________________________
Percent of time devoted to:
Didactic training (e.g. seminars, in-services, directed reading): _____
Other: _______________________________________ % ________
Other: _______________________________________ % ________
Supervision (*See Supervisor Instructions):
Primary Supervisor & Degree: __________________________________________________
License/Credential: Yes □ Please specify:_________________________________
Secondary Supervisor & Degree: ________________________________________________
License/Credential: Yes □ Please specify:_________________________________
Supervision Schedule: _________________________________________________________
___________________________________________________________________________
Methods of Supervision: □ Live □ Audio/Videotape □ Documentation Review
□ Other: _______________________________ □ Other: _______________________________
Training Goals
1.___________________________________________________________________
Objective 1:_________________________________________ ____________
Objective 2: _____________________________________________________
2.______________________________________________________ _____________
Objective 1:_________________________________________ ____________
Objective 2: _____________________________________________________
3. Ethics & Professional Practice:
Objective 1:_________________________________________ ____________
Objective 2: _____________________________________________________
4. Diversity & Multicultural Competence:
Objective 1:_________________________________________ ____________
Objective 2: _____________________________________________________
__________________________________________________ ____________
Student Signature: Date:
_________________________________________________ ____________
Supervisor Signature Date:
_________________________________________________ ____________
Clerkship Seminar Instructor Date:
________________________________________________ ____________
Deborah Lewis, Ph.D., ABPP Date:
Director of Training, Clinical Psychology
623-572-3867
Student Instructions and Recommendations:
You are responsible for filling out your training goals in conjunction with your site supervisor and your program. This training plan needs completed in its entirety and signed by you, your site supervisor and your clerkship seminar instructor. Then you need to turn it in to the Director of Training (Dr. Lewis).
There are several issues and requirements to keep in mind during your field training experiences. They are:
1) The requirements of your program,
2) What may help you become competitive in the Association of Post-doctoral and Internship Centers (APPIC) internship match process, and
3) Licensing requirements.
Your school requirements can be found in your institutions program documents. Students must successfully complete all program requirements.
The goal of your institution, and your training site, is to help you obtain the best possible training. The goal of field training is for students to become competent clinicians. Some field training experiences may not meet a certain requirement, for a variety of reasons, but may provide a good training experience.
Supervisor Instructions
Purpose: The training plan is to assure the quality, breadth, and depth of the training experience. It also provides a rationale for the experience in light of all of the student’s training experiences, to ensure that the overall field training sequence is organized, sequential, and meets the training needs of the trainee and provides competence services to the community.
Supervision: We ask that 10% overall time is in supervision.
Method of Student Evaluation: Students are evaluated quarterly. You will be sent an email with your username and password that will link you to the evaluation questions. Students can access the questions at any time in the Clinical Training Manual. Please review each evaluation with the student. They will be sent a copy.
Revised 1-25-10
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