Application for Postdoctoral Residency 2015-2016
Palm Beach County Youth Services Department
Residential Treatment and Family Counseling Division
100 Australian Avenue, Suite 210
West Palm Beach, FL 33406
(561) 233-4460
Fax (561) 233-4475
http://www.pbcgov.com/youthservices/counseling
Instructions: Complete this form by answering all questions. Incomplete applications will not be reviewed. After completion of this
application form, please email it along with a cover letter, a copy of your CV, a copy of your Doctoral Internship APPI, graduate
transcript, and a sample child/adolescent psychological evaluation (non-neuro) report to Shayna Ginsburg, Psy.D. at
sginsbur@pbcgov.org. The subject line of the email should be: Application for Postdoctoral Residency 2015-2016.
NOTE: To enter your responses, first click on the shaded areas of the text entry fields. Most text fields allow for text
longer than the shaded space (e.g., “Name” field); however, some fields are limited to the desired number of character
spaces (e.g., text boxes for short answer responses on page 2).
Name:
Mailing Address:
Home Telephone:
Cell Telephone:
Email:
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Doctoral Education in Psychology:
Program APA Accredited? (Y/N)
Program Name/Department/Institution:
Graduate Program Director:
Anticipated Completion Date:
Dissertation Topic:
Predoctoral Internship:
Program APA Accredited? (Y/N)
APPIC Member (Y/N)
Program Name/Department/Institution:
Predoctoral Internship Training Director:
List names and telephone numbers of references you have asked to provide letters of recommendation. Recommendation letters
should be sent to sginsbur@pbcgov.org. Note: One letter must be from a doctoral internship supervisor.
Reference 1:
Reference 2:
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I grant permission for Palm Beach County Youth Services Department to contact my references directly (Y/N):
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Clinical Experience
Instructions: Please respond to the following questions in complete sentences. Do not provide lists or bullets.
Briefly characterize your clinical orientation (keep responses limited to 1000 characters):
Therapy Experience: Summarize your experience, including diagnoses, modalities, and interventions used:
Child/Adolescent/Family Experience: Summarize your experience with these populations
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Testing/Assessment/Evaluation Experience: Summarize your experience, including ages and diagnoses
Teaching/Training/Presentation Experience: Summarize your experience teaching, providing training, and professional
presentations
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Other Information
Languages other than English you speak fluently:
Are you available for a personal interview at your expense?
Are you available for telephone/Skype interviews?
Will your dissertation be completed by September 8, 2015?
Will all your requirements for the Doctoral degree be completed by September 8, 2015?
Will you have officially graduated by September 8, 2015?
Please arrange for your Director of Clinical Training and your dissertation chair to confirm your anticipated doctoral completion
date. This may take the form of a letter of confirmation. Upon acceptance of the position, an official transcript with degree
conferral date will be required.
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