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APPLICATION
POSTDOCTORAL CLINICAL CHILD PSYCHOLOGY FELLOWSHIP PROGRAM
DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES
UNIVERSITY OF CALIFORNIA, DAVIS, MEDICAL CENTER
Please include with this application:
1.
2.
3.
4.
A cover letter specifying your aims for your fellowship year
Three letters of recommendation
A current curriculum vitae
A comprehensive psychological assessment report (with all client/patient identifiers removed)
Mail your application to:
Stacey Peerson, Ph.D., Program Director
University of California, Davis, Medical Center
Department of Psychiatry and Behavioral Sciences
2230 Stockton Blvd.
Sacramento, CA 95817-1419
Questions? Please e-mail Dr. Peerson. (stacey.peerson@ucdmc.ucdavis.edu)
Application Date
11/22/13
SECTION 1: BACKGROUND AND EDUCATIONAL INFORMATION
Applicant Name
Address
State
City
Country
E-mail
If you are not a U.S. citizen, do you have the legal right to accept employment in the United States?
Education and Training
Highest degree held in a mental health field
Degree in progress
Expected degree completion date
University/Graduate School
Department
Program
Address
Status of dissertation
Dissertation proposal approved:
Data collected:
Data analyzed:
Dissertation defended:
Expected date of completion:
Zip/Postal Code
If no dissertation is required, describe the status of any major project (if applicable).
Internship Training
Internship site
Type of setting
APA Accredited?
Start date
Expected date of completion:
Academic History
Graduate School/University
Major
Degree
Date completed
Undergraduate College/University
Major
Degree
Date completed
Undergraduate GPA:
Masters GPA:
Doctoral GPA:
Licenses and Certifications
Please list any licenses or certifications in mental health fields which would allow you to practice counseling or psychotherapy.
License/certification type
State
License/certification type
State
License/certification type
State
Honors and Awards
References
Name
Address
City
State
Zip/Postal Code
State
Zip/Postal Code
State
Zip/Postal Code
Country
E-mail
Name
Address
City
Country
E-mail
Name
Address
City
Country
E-mail
SECTION 2: CLINICAL EXPRIENCE
Briefly characterize your theoretical orientation and therapeutic approach. (Please limit your response to 500 words).
Test Administration
Please indicate all instruments used by you in your assessment experience, excluding practice administrations to fellow students.
To indicate that you have administered, scored, interpreted, and written a report for a test, count in both columns. Attach an
additional page to list any other tests that you have administered if there is not enough space under “Other Tests.”
CHILD/ADOLESCENT TESTS
Autism measures (e.g., CARS, GARS, ADOS, ADI-R, ASDS, SCQ)
Beery VMI
Caregiver/Teacher Rating Scales (e.g. BASC-2, CBCL, Conners)
Million (MACI & M-PACI)
MMPI-A
Peabody Picture Vocabulary Test
Projective drawings (e.g., house-tree-person, kinetic family drawing)
Projective sentences (e.g., RISB)
Roberts-2
Rorschach (select scoring system or enter type if "Other")
Self-report symptom measures (e.g., CDI, TSCC)
Structured diagnostic interview (e.g. DISC, KSADS)
TAT
TEMAS
TONI-3/TONI-4
Trail Making Test A & B
Vineland/Vineland II
WASI/WASI-II
WIAT-II
WISC-IV
Woodcock Johnson - III
WPPSI-III
WRAML/WRAML-2
WRAT-III/WRAT-IV
# Administered
and Scored
# of Reports
Written
OTHER CHILD/ADOLESENT TESTS
# Administered
and Scored
# of Reports
Written
ADULT TESTS
# Administered
and Scored
# of Reports
Written
Bender Gestalt
MCMI-III
MMPI-2
PAI
Projective drawings (e.g., house-tree-person, kinetic family drawing)
Projective sentences (e.g. RSIB)
RBANS
Rorschach (select scoring system or enter type if "Other")
Self-report symptom measures (e.g. Beck Depression Inventory)
SIRS
Structured diagnostic interview (e.g. SADS, DIS)
TAT
Trail Making Test A & B
WAIS-III/WAIS-IV
WMS-III/WMS-IV
WRAT-III/WRAT-IV
OTHER ADULT TESTS
# Administered
and Scored
# of Reports
Written
Integrated Report Writing
Please indicate the number of supervised integrated psychological assessment reports have you written for each of the following
populations. This section should NOT include reports written from an interview that consists of only history-taking, a clinical interview,
and/or only the completion of behavioral rating forms. The definition of an integrated psychological assessment report is a report that
includes a review of history, results of an interview and at least psychological tests from one or more of the following categories:
personality measures, symptom report measures, intellectual tests, cognitive tests, and neuropsychological tests. These are synthesized
into a comprehensive report providing an overall picture of the patient/client.
Infants/toddlers
Children/adolescents
Adults
SECTION 3: PROFESSIONAL CONDUCT
Please answer ALL of the following questions.
Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor, education or training
institution, healthcare institution, professional association, or licensing/certification board?
Are there any complaints currently pending against you by a supervisor, education or training institution, healthcare
institution, professional association, or licensing/certification board?
Has there ever been a decision rendered against you in a civil suit relative to your professional work, or is any such
action pending?
Have you ever been suspended, terminated, or asked to resign by a training program, practicum site, or employer?
Have you ever been of an offense against the law other than a minor traffic violation?
Have you ever been convicted of a felony?
If you answered "Yes" to any of the previous questions, please attach an explanation on a separate sheet of paper.
SECTION 4: APPLICANT'S CERTIFICATION
In checking the box to the left:
1. I certify that all of the information provided in this application is true and correct to the best of my knowledge. I understand
that any significant misstatement in, or omission from, this application may be cause for denial of selection for the
fellowship or dismissal as a fellow.
2. I authorize the fellowship site to consult with persons and institutions with which I have been associated regarding my
professional competence, character, and ethical qualifications.
3. I release from liability all fellowship staff for acts performed in good faith and without malice in connection with evaluating
my application, credentials, and qualifications. I also release from liability all individuals and organizations that provide
information to the fellowship site in good faith and without malice concerning my professional competence, ethics,
character, and other qualifications.
Applicant Signature
Date