Summary Qualifications and Relevant Experience Form
Candidate Name: ______________________________________ Reference/ ID Number: ______________________________
1. Do you hold an Honours Psychology Degree or a recognised Conversion Qualification in Psychology (e.g. HDip in Psychology)
from a University or third level institution in Ireland or the UK?
YES
NO
2. Can you confirm that the above qualification confers eligibility for Graduate Membership of the Psychological Society of Ireland
or the Graduate Basis for Chartered (GBC) membership of the British Psychological Society?
YES
NO
Important Note: If you have any doubts concerning your eligibility for Graduate Membership of The Psychological Society of Ireland you should
obtain clarification prior to submitting your application. If you obtained your primary honours degree in psychology or your conversion qualification
in psychology outside the Republic of Ireland you must provide evidence of eligibility for Graduate Membership of the Psychological Society of
Ireland or the Graduate Basis for Chartered (GBC) membership of the British Psychological Society otherwise your application will not be
considered.
3. Indicate either your Psychology Degree or Conversion Qualification grade here only.
(Please indicate your relevant qualification grade by entering X in one column below only)
Primary Psychology Degree
(e.g. BA (Hons) or BSc (Hons) in
Psychology)
Conversion Qualification
(e.g. HDip in Psychology)
1st
2.2
2.1
3rd
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Summary Qualifications and Relevant Experience Form
4. Relevant Work Experience (please add additional rows as needed and complete all columns)
Note: You must provide all required information below otherwise your experience will be disregarded for calculation purposes.
Job title*
Employer Name & Address
Indicate if Paid/Unpaid
Assistant Psychologist supervised by a Clinical
Psychologist
(Unpaid)
HSE West
Merlin Park Hospital
Co. Galway
Name and Full Professional
Title of your Primary
Supervisor
Dr Sheila Wilson
Senior Clinical Psychologist
Period of
Employment
December ‘13
to May ‘14
Duration
of Post
(in months)
6
Hours Per
Week
Official
use only
15
* Note: For coding purposes use the following job titles in Section 4
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
Psychologist with Post-Graduate Professional Training (e.g. Educational/ Counselling Psychologist)
Assistant Psychologist (or equivalent title) supervised by a Clinical Psychologist
Research Assistant / Research Associate / Research Fellow supervised by a Clinical Psychologist
Professionally qualified Social Worker, Occupational Therapist, Speech & language Therapist, Physiotherapist
Research Assistant / Research Associate / Research Fellow not supervised by Clinical Psychologist
Graduate Psychologist under supervision of a Psychologist (not a Clinical Psychologist)
ABA Tutor / Behaviour Support Specialist, Senior/Specialist Nurse
Graduate Psychologist under supervision of a related professional discipline (e.g. Psychiatrist)
Psychology Tutor/Lecturer
Senior or Specialist Nurse
Registered Nurse, Counsellor, Addictions Counsellor
Play therapist, Care Worker, Residential Worker, Support Worker,
Other Health or Social Care roles not otherwise specified
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Summary Qualifications and Relevant Experience Form
5. Additional academic achievements (note: not all applicants will have additional academic achievements).
Peer-reviewed
Publications
References here (e.g. O’Dwyer, M. (2015). Burnout in clinical psychology training. Clinical Psychology Forum, 14 (8), 4-15.)
(APA Format Please)
Other Publications
References here
(e.g. HSE Report)
Conference Presentations
References here
Prizes, Merits,
Scholarships or
Distinctions
Description here for each
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