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Clinical Psychology Doctoral Program - Clinical Training Office

Statement of Readiness for APPIC/APA Application

This form provides the Director of Clinical Training with the necessary information to complete the Academic Program’s Verification of Internship Eligibility and Readiness (AAPI Part 2). Failure to obtain all of the required signatures may delay a student’s internship application process.

Student Name: Date:

Part I: To be filled out by the Registrar’s Office.

1.  Did the student receive a B or above in the following courses? (IP = In Progress)

a.  Case Consultation I (PSY 685) Yes No IP Not taken yet

b.  Case Consultation II (PSY 686) Yes No IP Not taken yet

c.  Case Consultation III (PSY 687) Yes No IP Not taken yet

d.  Family Systems Interventions (PSY 740) Yes No IP Not taken yet

e.  Cognitive-Behavioral Therapy (PSY 741) Yes No IP Not taken yet

f.  Child and Adolescent Interventions (PSY 743) Yes No IP Not taken yet

g.  Group Therapy (PSY 681) Yes No IP Not taken yet

h.  Psychodynamic Interventions (PSY 742) Yes No IP Not taken yet

i.  Couples Interventions (PSY 744) Yes No IP Not taken yet

2.  Student’s cumulative PGI GPA is ______.

3.  Did the student pass the Comprehensive Exam? Yes No

4.  Student currently has _____ incompletes on his/her transcript.

5.  Are there any complaints currently pending against this student? Yes No

If yes, please describe here:

6. Were any complaints filed in the past and found to be legitimate? Yes No

If yes, please describe here:

Registrar Signature Date

Part II: To be filled out by the Clinical Training Office Coordinator.

The student received _____ acceptable _____ unacceptable ratings on the Professional Behavior Evaluation Form.

The student received the following Global Assessment and Review ratings:

Professional Behavior _____ Relationship _____ Assessment _____ Intervention _____

Clinical Training Office Coordinator Date

Part III: To be filled out by the Clinical Training Office Coordinator:

The student will have successfully completed two practicum rotations by the time he/she begins an internship placement.

Hours through October 31, 2008 Hours estimated after November 1, 2008

Intervention Assessment Intervention & Assessment

Support Hours Support Hours

Supervision Supervision

Clinical Training Office Coordinator Date

Comments:

Revised 6/2/08