MEDICAL/CLINICAL PSYCHOLOGY DOCTORAL PROGRAM
CLINICAL PRACTICUM AGREEMENT and TRAINING PLAN
Revised October, 2015
Received on ________________(date)
This form must be completed, signed, and submitted to the Program Director no later than 2 weeks after the practicum begins.
Students: Please scan to a PDF. After verifying the quality and orientation of the scan, please send from your e-mail account to ecook@uab.edu.
1. Student: _______________________________________________________________________________________
2. Term of Agreement (not to exceed 1 year): Starting date: __________________ Ending date: ________________
3. Primary Supervisor (Please specify ONE licensed psychologist or other licensed mental health provider who will provide or
oversee supervision, sign evaluations, and verify hours): _____________________________________________________
E-mail:___________________________________________
Licensure:
□ Psychologist
Phone:________________________________
□ Other (enter field of licensure):______________________________
4. List any secondary supervisors (other licensed mental health providers who will provide supervision). If not licensed in
Psychology, include field of licensure in parentheses. These individuals provide feedback to the student and the primary
supervisor but do not sign off on evaluations or hours: ______________________________________________________
______________________________________________________________________________________________.
5. If a supervisor-in-training (clinical psychology graduate student, intern, or post-doc) will provide regular
supervision, please name him or her here: __________________________________________________________.
Status: □Medical/Clinical Psychology graduate student
□UAB Psychology intern
□Other clinical psychology graduate student
□Post-doc fellow with clinical, counseling or school psychology PhD
These individuals provide feedback to the student and Primary Supervisor. Medical/Clinical student supervisors should
submit a separate agreement/training plan with the same Primary Supervisor as listed above for training in supervision.
Note: Only face-to-face meetings with the above-named licensed supervisors and supervisors-in-training may be
logged as supervision for internship purposes. However, all supervision associated with this practicum should
be logged under the Primary Supervisor, who is responsible for the training provided.
6. Facility/Clinic: Check one or more, and, where applicable, use this facility name in logs of activities (e.g.,
MyPsychTrack). Consult the Program Director regarding facilities/clinics that are not listed.
□ 1917 (HIV) Clinic
□ Ackerson and Associates
□ Alabama Neurobehavior
□ Beacon Addiction Treatment Center
□ Bair, Peacock, McDonald and McMullan
□ Carver High School DBT program
□ CPM–Geriatrics
□ CPM–Initial Psychotherapy Practicum
□ CPM–Inpatient Mental Health
□ CPM–Outpatient Mental Health
□ CPM–Transplant Evaluation
□ CPM–Medical Consultation/Liaison
□ Children’s of AL–Hematology/Oncology
□ Children’s of AL–Inpatient Mental Health
□ Children’s of AL–Intensive Feeding Program
□ Children’s of AL–LEAH Adolescent Clinic
□ Children’s of AL–Med. Consultation/Liaison
□ Children’s of AL–Neuropsychology
□ Children’s of AL–Outpatient Mental Health
□ Children’s of AL–Sleep Medicine
□ Civitan-Sparks Preschool ASD Clinic
□ Civitan-Sparks School-age ASD Clinic
□ Civitan-Sparks Screening Clinic
□ Civitan-Sparks CDC/ITC/MDC
□ Civitan-Sparks Newborn Follow-Up Clinic
□ Civitan-Sparks Behavioral Assessment Clinic
□ Civitan-Sparks PEERS group
□ Civitan-Sparks Psychoeducational Clinic
□ Civitan-Sparks Project Heroes
□ Civitan-Sparks Outpatient Psychotherapy
□ Community Psychiatry
□ The Doleys Clinic–Pain and Rehab Center
□ Eat Right Program
□ Foundations Early Learning & Family Center
□ Glenwood–Outpatient Services
□ Glenwood–School-based Programs
□ Grayson & Associates
□ Mitchell’s Place
□ Neurology Division of Neuropsychology
□ Over the Mountain Psychological Services
□ Palliative and Comfort Care Unit
□ Psychiatry Mood & Anxiety Disorders Clinic
□ Shelby Psychological Services
□ Spain Rehab Center–Stroke Service
□ Spain Rehab Center–Cardiopulmonary Rehab
□ Spain Rehab Center–Traumatic Brain Injury
□ Spain Rehab Center–Spinal Cord Injury
□ Spain Rehab Center–Outpt Neuropsychology
□ Spain Rehabilitation Center–Polytrauma
□ Supportive Care and Survivorship Clinic
□ TELECARE Study
□ UAB Highlands Pain Clinic
□ VA Blind Rehabilitation Center
□ VA Outpatient Substance Abuse Clinic
□ VA Primary Care Mental Health Team
□ VA PTSD Outpatient Psychotherapy
□ VA Geropsychology
□ VA Neuropsychology
□ VA Rehabilitation Neuropsychology
□ VA Transplant Evaluation
7. Will the training be provided in the context of an assistantship or other paid employment?
□Yes
□No
8. Briefly describe the training plan, including types or names of assessment instruments and/or empiricallysupported interventions that the student will learn, as well as other training experiences such as supervision of
other students, consultation-liaison, and/or interdisciplinary care. (Please do not reference other documents.):
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
9. Is the practicum training appropriate to the student’s academic preparation (prior coursework) and does it
build, in complexity and breadth, on any prior clinical practicum training?
□Yes
□No
10. Estimate the average number of hours/week to be spent in:
Direct patient contact:___________
Supervision:____________
Support activities:____________
Note: Program policy requires at least 15 minutes of face-to-face supervision for each hour of direct
patient contact (20 minutes/hour for the introductory psychotherapy practicum).
11. Indicate any supervision formats that the supervisor(s) and/or supervisor-in-training (if applicable) will use:
□ Live/direct observation (e.g., through a 1-way mirror, CCTV, or presence during assessments or therapy)
□ Watching video recordings of assessments or therapy
□ Individual supervision
□ Listening to audio recordings of assessments or therapy
□ Group supervision
□ Discussion of sessions / test results / reports
Note:
Live observation or review of recorded sessions are the preferred methods for monitoring and providing feedback.
Supervisor time spent in live/direct observation may be logged as patient contact or supervision, or split between the
two, but no time may be double-logged. Supervisor time spent reviewing work products (e.g., reports, notes, test
protocols and/or recordings) may be logged as supervision if the student is present for and participates in the review.
12. Indicate methods that will be used to increase student’s awareness and competence with respect to influences of
individual diversity (e.g. age, gender, race/ethnicity, culture, disability status, and/or sexual orientation or
identity) on patient behavior and/or the clinical interaction?
□ Readings (e.g., articles, chapters, culturally-related material in the DSM)
□ Review of group-specific norms on tests
□ Review of epidemiological data
□ Discussion of diversity issues in supervision
□ Other (specify): __________________________
□ None
Note: Students must record clinical hours and activities throughout the term, and the supervisor must verify
these records at the end of each term. Methods for recording and verification will be provided via e-mail by
the Program Director.
Student signature: ______________________________________________________ Date: ____________________
Primary supervisor signature: ___________________________________________
Date: ____________________
Supervisor-in-training signature (if applicable): _________________________________ Date: ____________________
GSC Chair Signature: ___________________________________________________ Date: ____________________
Program Director Signature: _____________________________________________ Date: ____________________
Additional Information regarding Clinical Supervision
Supervision may be provided on an individual or group basis, or a combination of the two. When group supervision is provided, the amount of time
spent in review of individual cases should vary as a function of patient and student characteristics. A brief review should be presented by the student
after each clinical contact in order to maintain a minimum level of supervision, and a thorough review of each case should be undertaken after every
4-5 clinical contacts….Regardless of the supervision format, a meeting should occur at the beginning of the practicum, before any direct clinical
services are provided, to facilitate clear communication regarding training goals, diversity-related opportunities at the training site, and supervision
arrangements. This Clinical Practicum Agreement/Training Plan form should be reviewed and completed at this meeting.
At the end of each term an individual meeting should also occur so that the supervisor can provide feedback on progress achieved as well as strengths
and weaknesses observed. The Clinical Practicum Evaluation form can provide a framework for this discussion. The completed evaluation form is
due to the Program Director by the last day of the final exam period of any term in which intervention or assessment hours are logged.
Competencies to be evaluated are listed on the next page.
Clinical competencies to be rated on the Clinical Practicum Evaluation Form at the end of each academic term:
Goal 1.
Goal 2.
Goal 3.
Goal 4.
Prepare the student for internship through the enhancement of his or her clinical knowledge.
a. Student demonstrates knowledge of theories and techniques regarding psychological assessment.
1) Knowledge of the DSM and its proper usage.
2) Knowledge of appropriate administration and interpretation of assessment instruments.
3) Knowledge of theories and evidence regarding assessment interview formats.
4) Understanding of common medical and pharmacologic issues relevant to assessment.
b. Student demonstrates knowledge of various forms of treatment, especially empirically supported treatments and their appropriate use.
1) Knowledge of theoretical orientations and their use to guide treatment
2) Understands the appropriate use of therapeutic approaches
3) Recognizes the impact of cultural and individual differences upon the therapeutic process.
4) Understands both the value of ESTs and the value of individualizing therapy
c. Student demonstrates knowledge of the interaction between the science and practice of clinical psychology.
1) Understanding of the impact of science upon the practice of clinical psychology
2) Understanding of the impact of the practice of clinical psychology upon science
Prepare the student for internship through the enhancement of his or her clinical skills.
a. Student initiates and maintains appropriate clinical relationships.
1) Establishment of strong positive therapeutic alliances
2) Maintenance of appropriate boundaries with all patients
3) Ethical decision-making regarding clinical relationships.
b. Student conducts psychological assessments using appropriate techniques.
1) Able to choose assessment instruments appropriate to case needs.
2) Able to interpret testing and express results clearly.
3) Able to use psychological interview for assessment.
4) Supervisor observes student drawing valid inferences from interviews.
5) Case conceptualization is credible in supervision meetings.
6) Case conceptualization is credibly in written reports.
7) Able to make appropriate DSM diagnoses.
c. Student implements appropriate psychological treatments.
1) Case conceptualization for treatment planning: Draws appropriate implications for an ideal treatment plan
2) Case conceptualization for individualized treatment planning: Uses case conceptualization to draw appropriate implications for a
treatment plan that considers idiosyncrasies of the patient’s individual situation.
3) Conduct of individual therapy: Adequate treatment implementation based on developed treatment plan.
4) Conduct of group therapy: Supportive of the primary co-therapist, and rarely counters co-therapist efforts or distracts from therapeutic
group process.
5) Consideration of cultural and individual diversity issues: Student is sensitive to and effectively addresses diversity issues during
assessment or therapy.
Prepare the student for internship through enhancement of his or her professional attitudes and behaviors.
a. Student demonstrates a level of professionalism that is appropriate to the practice of clinical psychology.
1) Appropriate engagement in supervision: Student is open to constructive feedback for all professional activities and to questioning his or
her own professional behavior
2) Appropriate verbal communication with other professionals/staff: Student engages in dialogue with fellow professionals in respectful
sharing collaboration.
3) Appropriate written communication with other professionals/staff: Student writes relatively brief and organized communications based
on sound observation, interpretation of tests, and other assessment data.
4) Attendance: Student attends all agreed scheduled activities and provides phone or e-mail notice if he/she cannot attend for a legitimate
reason.
5) Ability to utilize supervision: Student changes his or her behavior as a function of supervisor’s feedback.
6) Motivation for and interest in the profession: Student’s shows interest in the profession; e.g., reads relevant journal articles, attends
conferences and workshops, and engages in discussion of important professional matters.
7) Absence of behavioral problems that hinder professional services or ability to benefit from supervision.
b. Student recognizes and practices ethical behavior.
1) Understanding and examination of ethical considerations for clinical practice: Student verbalizes knowledge of and concern for ethical
issues in any aspect of professional practice, and takes appropriate action based on that knowledge and concern.
2) Recognition of ethical considerations related to cultural and individual diversity: Student verbalizes knowledge of and concern for ethical
issues in any aspect of professional practice related to cultural or individual diversity.
3) Understanding of the need for continuing education to maintain competence. Student takes advantage of local, national and/or
international educational and training opportunities, which increase knowledge and competence.
Prepare the student for internship through enhancement of knowledge, skills, and professionalism in the area of clinical supervision.
1) Knowledge: Student is able to articulate an approach to supervision that is grounded in research.
2) Knowledge: Student provides supervisees with feedback that is based in substantive knowledge of the area being supervised.
3) Skill: Student is observed to establish of strong positive supervisory relationships/alliances with supervisees and other trainees with whom he
or she is charged with providing feedback.
4) Skill: Student provides supervisees with feedback that promotes the supervisee’s self-assessment and development by maintaining an
appropriate balance between support and challenge/critique.
5) Skill: Student encourages and uses evaluative feedback from supervisees.
6) Professionalism: Student articulates and is observed to act on the basis of his or her ethical responsibilities to patients/clients, supervisees, and
his or her supervisor.
7) Professionalism: Student behaves toward supervisees in ways that respect diversity in all its forms.
8) Professionalism: Student keeps adequate records of supervision and keeps his or her supervisor well-informed of supervisees’ progress,
training needs and concerns.