Psychological Health Affiliates

Clinical Experience Questionnaire

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Psychological Health Affiliates

Clinical Experience Profile

Please save this document on your computer, using the following file naming format: Lastname, Firstname (YYYY-MM-DDDD, Clinical Experience Qsnr) [e.g., Smith, John (2007-06-30, Clinical Experience Qsnr)]. After saving, complete the form on the following pages. Use the mouse or tab key to move quickly from one answer box to the next. Feel free to make comments at the end of the form. Save the document again when you have finished, and email it, along with your other application materials (including your curriculum vita), to: .

Name: / Date:
Address:
Phone: / Email:
Clinical Activity / NO
EXPOSURE / COURSE WORK ONLY / MINIMAL
(< 5 Clients) / MODERATE
(6-12 Clients) / SIGNIFICANT
(>12 Clients) /
INDIVIDUAL THERAPY
Early Child (<6 Years)
Abuse Victim
Anxiety Disorder
Obsessive Compulsive Disorder
Attention Deficit Disorder
Conduct Disorder/Oppositional Disorder
Dissociative Disorder
Emotionally Disturbed
Mentally Retarded
Neurological
Psychotic
Other
Later Child (7-12)
Abuse Victim
Anxiety Disorder
Obsessive Compulsive Disorder
Attention Deficit Disorder
Conduct Disorder/Oppositional Disorder
Dissociative Disorder
Emotionally Disturbed
Mentally Retarded
Neurological
Psychotic
Other
Adolescent (13-18 years)
Abuse Victim
Anxiety Disorder
Obsessive Compulsive Disorder
Attention Deficit Disorder
Conduct Disorder/Oppositional Disorder
Dissociative Disorder
Emotionally Disturbed
Mentally Retarded
Neurological
Psychotic
Other
Adult (18-25 years)
Abuse Survivor
Adjustment Disorder
Attention Deficit Disorder
Anxiety
Crisis
Depression
Dissociative Disorder
Mentally Retarded
Neurological
Eating Disorder
Obsessive Compulsive Disorder
Personality Disorder
Domestic Violence
Psychotic
Substance Abuse
Other
Adult (26-60)
Abuse Survivor
Adjustment Disorder
Attention Deficit Disorder
Anxiety
Crisis
Depression
Dissociative Disorder
Mentally Retarded
Neurological
Eating Disorder
Obsessive Compulsive Disorder
Personality Disorder
Domestic Violence
Psychotic
Substance Abuse
Other
Older Adult (over 60)
Abuse Survivor
Adjustment Disorder
Attention Deficit Disorder
Anxiety
Crisis
Depression
Dissociative Disorder
Mentally Retarded
Neurological
Eating Disorder
Obsessive Compulsive Disorder
Personality Disorder
Domestic Violence
Psychotic
Substance Abuse
Other
Family Therapy
Couples or Marital Therapy
PSYCHOLOGICAL ASSESSMENT
Intelligence/Neuro Testing
* WAIS
* KABC
* WISC
* McCarthy Scales
* K-FAST
* Wechsler Memory
* WRAML
* Halstead-Reitan
* Luria-Nebraska
* Other
Personality Testing
* MMPI
* MCMI
* MACI
* 16PF
* Myers-Briggs
* SCL-90
* Rorschach
* Other Projectives (list)
* Other Objectives (list)
Psychoeducational Testing
* Woodcock Reading Mastery Test
* Woodcock-Johnson, Full Battery
* Gray Oral Reading Test
* Wide Range Achievement Test
*Wechsler Indiv. Achievement Test
*Curriculum-Based Measures
*Participated in MDE Meetings
*Other
Neurological Screening
Vocational Testing
Total Number Evaluations Done
Other Specialty Areas ---

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