Hong Kong Psychological Society
Division of Counselling Psychology (DCoP)
Application Form for Membership
Please read the DCoP Membership Guidelines before completing the application form and checklist.
I.
Personal Particulars
Name in Full (English) (Surname first)
Title
Name in Chinese
Date of Birth
Telephone No.
(Home)
(Office)
E-mail Address
Correspondence Address
Residential Address (if different from above)
Current HKPS
membership status*
FELLOW
ASSOCIATE
FELLOW
GRADUATE
MEMBER
AFFILIATE
* Please circle as appropriate – You must be a HKPS member to be eligible for the divisional membership.
II.
The Membership Category of the Division Applied for
 Full Membership
 Affiliate Membership
III.
Academic Qualifications (in chronological order)
Please attach degree certificates (copy) and official transcripts as supporting evidence.
From
To
Month/Year
Version Jan 5, 2015
Name of Academic Institution /University
(please specify country)
Page 1 of 8
Degree
Obtained
Date of Award
IV.
Supervised Practicum/Internship (official supporting documents must be attached)
Please report your supervised practicum/internship within the postgraduate degree in the reverse
chronological order (i.e., the most recent one appears first in the document). Evidence must be attached
to certify the stated practicum and supervision hours (such as endorsement letters from supervisors,
supervisor’s signed log sheets including supervised practicum and direct supervision hours,
testimonials, etc.)
Practicum/Internship Title: ________________________________ (e.g., Internship III)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Internship II)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
Version Jan 5, 2015
Page 2 of 8
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Internship I)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Advanced Practicum III)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
Version Jan 5, 2015
Page 3 of 8
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Advanced Practicum II)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Advanced Practicum I)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
Version Jan 5, 2015
Page 4 of 8
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Practicum II)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
(e.g., ABC Family Centre)
Practicum/Internship Title: ________________________________ (e.g., Practicum I)
Practicum/Internship Period
(mm/yyyy – mm/yyyy)
Name of Practicum/Internship Site
(e.g., 09/2013-12/2013)
Type of Setting/Populations
(e.g., children with emotional & behavioral problems)
Clinical Supervisor
(Name, Job Position, Professional Degrees
& Professional Memberships)
(e.g., Dr. John Chan; Assistant Professor, Department of Psychology,
XX University; PhD in Counselling Psychology, YY University;
Member of DCoP HKPS)
Supervised Practicum Hours
(e.g., 50 hours, logsheet attached)
Direct Face-to-Face Supervision Hours #
(e.g., 10 hours, logsheet attached)
(e.g., ABC Family Centre)
If you have more practicum/internship experiences, please use additional sheet of paper.
# Details of direct face-to-face
supervision hours stated in the
tables above:
1. Total Hours of Individual Supervision
(including direct observation in counselling by supervisor)
Hours
2. Total Hours of Group Supervision
Hours
Grand Total Hours of Supervision (1 + 2)
Hours
Version Jan 5, 2015
Page 5 of 8
Further Clinical Supervision and Professional Training after Graduation
Please indicate in the reverse chronological order (i.e., the most recent appears first)
From
To
Month/Year
Clinical Supervisor
(Name, Job Title, Name of Agency/Institution)
From
To
Month/Year
V.
Name of Institution/Agency
Supervision Format
(Individual or Group)
Name of Training Program
Direct Face-to-Face
Hours
Number of
Hours
Level
Obtained
Work Experiences (in the reverse chronological order)
Please list the appointments held after graduation.
From
To
Month/Year
Name and Address of Employment
Job Title
(full-time or part-time, please specify)
VI.
Declaration
I declare that all the information and documents provided in my application are accurate and correct. I
understand that any false declaration of information provided may lead to disciplinary actions and
disqualification of my DCoP membership. My personal data will also be held according to the rights
and responsibilities laid out by the Personal Data (Privacy) Ordinance and adopted by the HKPS.
Application Date: __________________________
Version Jan 5, 2015
Signature: ______________________________
Page 6 of 8
VII. References
The application must be supported and signed by a Proposer and Seconder, who must be members of
the Hong Kong Psychological Society Ltd and at least one has to be a member of the Division of
Counselling Psychology - HKPS.
Proposer:
HKPS Membership No. :
Name
(
)
Signature
Date
Seconder:
HKPS Membership No. :
Name
(
)
Signature
Date
Note: The completed application form together with supporting documents should be sent to the following
address:
The General Secretary
Hong Kong Psychological Society
Room 705, United Building,
17-19 Jubilee Street,
Central, Hong Kong
Version Jan 5, 2015
Page 7 of 8
Checklist for Membership Application to the Division of Counselling Psychology, HKPS
To all applicants: Please go through the checklist and check (√) that you have completed all the
required information and provided supporting documents for application vetting.
Requirements
2
Have read the DCoP Membership Guidelines (available on the DCoP
website) and understood all the requirements before filling in the form
Have clearly stated all my academic qualifications in the form
3
Have attached my official transcripts of the program of study
4
Have attached a copy of my degree certificates
5
Have attached the course outlines
(particularly for Overseas training programmes)
Have indicated clearly the total hours of supervised practicum (Section IV of
the form)
Have indicated clearly the total hours of direct face-to-face clinical
supervision (Section IV of the form)
Have indicated clearly the breakdown of direct face-to-face clinical
supervision hours (Section IV of the form)
Have indicated further clinical supervision and professional training obtained
after graduation, if any (Section V of the form)
Have indicated clearly my work experience after graduation, if any (Section
VI of the form)
Have read carefully the declaration statement before signing the form
1
6
7
8
9
10
11
12
Have provided the name, signature, and membership number of my 2
References (one has to be a DCoP member)
Version Jan 5, 2015
Page 8 of 8
Please check
(√)