Application Materials
The following information and documentation is required to complete your application
Application and Qualifications
a) Completed application form to our Child and Adolescent Psychiatry Residency
b) Confirmation of Access to University of Washington School of Medicine Graduate
Medical Education Program Information (Page at end of application form)
c) Personal statement by resident
d) Current CV
e) Letters of Recommendation (3)*
f) Transcript from Medical School
g) USMLE Scores (copy of official transcripts or PDF of Score Report are acceptable)
h) Dean’s Letter
*Includes letter from General Psychiatry Residency training director, which documents the
resident’s training experiences and identifies any specific areas of general psychiatry
training remaining to be completed at the time of transfer from the general psychiatry
residency into our child and adolescent psychiatry residency
Child and Adolescent Psychiatry Residency Application
UNIVERSITY OF WASHINGTON AFFILIATED HOSPITALS
Department of Psychiatry and Behavioral Sciences
Division of Child and Adolescent Psychiatry
Seattle, Washington
Date ___/___/___Year of Residency you are Applying For R-___ To Begin ____/___/___
NAME______________________________________________________ ____________
Last
First
Middle
Previous
PRESENT ADDRESS
__________________________________________________________
__________________________________________________________
__________________________________________________________
TELEPHONE ( ) ______________ (
Home
S.S # ____ ____ ____
) ____________________ Email___________________
Work
B.D. ____/____/___ Birthplace __________________
City
(If a graduate of a foreign medical school - how do you qualify?)
____
State
ECFMG Cert___________ECFMG#____________Visa Type _____ Visa #___________
PREMEDICAL EDUCATION
College/Location
Major Area of Study
Dates/Attendance
Degree/Date
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________________________________________
MEDICAL EDUCATION
College/Location
Major Area of Study
Dates/Attendance
Degree/Date
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________
INTERNSHIPS, RESIDENCIES, AND FELLOWSHIPS
Name of Hospital
Location
Specialty Begun and Completed
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________
The University of Washington provides equal opportunity in education on the basis of race, color, national origin, and
sex in accordance with Title VI of Civil Rights Bill of 1964 and the Title IX of the Education Amendments and
Sections 799A and 855 of the Public Health Service Act.
REFERENCES
Please ask the Dean's office of your medical school to send a letter of reference and a transcript of your
medical school record. A minimum of three letters of recommendation are required from faculty of
your psychiatry residency or hospitals where you have worked. Additional recommendations may be
added. List all names below. ONE OF THE LETTERS MUST BE FROM THE TRAINING
DIRECTOR OF YOUR GENERAL PSYCHIATRY TRAINING PROGRAM
NAME & TITLE
TYPE OF CONTACT INSTITUTION, CITY, STATE
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________
Membership in Professional Societies____________________________________________
Honors, Scholarships, Grants___________________________________________________
Licensed in what state(s)
YES answers to the following questions require written explanation on a separate sheet. Positive responses to
questions do not necessarily preclude acceptance
Have you ever been involved in a malpractice lawsuit or claim (whether or not you were
individually named) as a defendant?
Yes No
Have you ever been called before any entity for questioning concerning unprofessional
conduct, competence, negligence, unsafe practices, or mental or physical impairment?
Yes
No
Has a medical license ever been denied, revoked, suspended or restricted?
Yes
No
Have you ever been addicted to, or treated for addiction to, a controlled substance,
drug, or chemical?
Yes
No
Have you ever used a prescription drug, including controlled substance, for other
than therapeutic purposes?
Yes
No
Are you currently suffering from any disability or illness (mental or physical) which
could affect your ability to fully practice medicine?
Yes
No
Personal Statement: Write a brief narrative discussing your interest in the field of child psychiatry and your ultimate
professional objectives. Are you interested in an academic career in teaching and research, private practice,
administration, or other areas? How much subsequent training do you plan?
I have read and understood the instructions for the completion of this application. I certify that the information
submitted in these application materials is complete and correct to the best of my knowledge. I understand that any
false or missing information may disqualify me for a position.
Signature of Applicant ______________________________________
SEND COMPLETED APPLICATION TO:
Contact Information:
Date _____/_____/_____
Christopher K. Varley, M.D.
Training Director, Division of Child and Adolescent Psychiatry
c/o Shirin Salzer
Seattle Children’s Hospital
4800 Sand Point Way, N.E. - W3636
Seattle, Washington 98105
Shirin Salzer, Program Coordinator, shirin.salzer@seattlechildrens.org, 206-987-3268
Christopher K Varley, Program Director, cvarley@u.washington.edu, (206) 987-3268
Department of Psychiatry and Behavioral Sciences
Child and Adolescent Psychiatry Residency Training Program
Access to University of Washington School of Medicine
Graduate Medical Education Program Information
I have been notified that the following documents are available on the University of Washington
Graduate Medical Education Website.

Resident (Fellowship) Position Appointment:

Eligibility and Selection Policy

Visa Policy
http://uwmedicine.washington.edu/Education/Graduate-Medical-Education/PoliciesProcedures/Pages/default.aspx
Print Name:
______________________________
Signature:
_______________________________ Date: ________________