APPLICATION FORM FOR SCRUTINY UNDER
DIRECTIVE 2005/36/EC
OF PROFESSIONAL QUALIFICATIONS IN
CLINICAL PSYCHOLOGY
PLEASE READ INFORMATION NOTE AND GUIDE CAREFULLY BEFORE
COMPLETING THIS FORM
PLEASE TYPE AND SIGN THIS FORM
(hand written forms will not be accepted)
A. PERSONAL DETAILS
Surname: ___________________________________ Title: ___________________
Previous surname, if any: ______________________________________________
First name(s): ________________________________________________________
Date of birth: Day__ __ Month__ __ Year__ __ __ __
Address for correspondence:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Email address: _______________________________________________________
Contact telephone number: ___________________________________________
Citizenship: __________________________________________________________
(please submit a witnessed copy photographic ID)
Residency:
if you are neither Swiss nor an EEA national1, are you legally resident in Ireland?
YES □
NO □
(If yes, please submit a witnessed copy of:
(a) your certificate of registration issued by the Garda National Immigration Bureau and showing the
immigration stamp; and
(b) passport endorsement.
(The period of permission shown in the certificate and the passport should match.))
1
EEA (European Economic Area) comprises Member States of the European Union, Iceland,
Liechtenstein and Norway.
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Eligibility to practise in the country in which qualification was obtained
Are you eligible to practise as a psychologist in the country in which qualification was
obtained?
YES □
NO □
See also Section I
Contact details (name, address, telephone
number, email) of the national competent
authority which should verify that your
qualification meets the standard to practise
in the country in which qualification was
obtained2
(Please submit a witnessed copy of evidence of the qualification giving access to the profession,
translated into English if necessary)
Membership of professional body
If you are a member of any psychological societies please give details in the table
below:
Name of Society
Contact address
Membership
number
Membership
status
Statutory Registration
YES □ NO □
Does statutory registration exist in your
country?
If yes are you statutorily registered?
(if yes please submit a witnessed copy of your
registration document)
YES □ NO □
Registration number:
Period of registration:
Scope of practice:
Please give contact details of registration body
(name, address, telephone number, email)
2
If you are an EEA national, please refer if necessary to the contact point for Directive 2005/36/EC in
your home Member State.
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B. QUALIFICATIONS IN PSYCHOLOGY
Please list all your degrees and qualifications in psychology in chronological order, starting with the first.
Full title of the course as
named by the degree
awarding authority
Undergraduate
Degree and
grade obtained
Start date,
completion date,
date awarded
(month & year)
Type of study and
assessment method
Name of university,
institute, college or other
degree awarding
authority
Name of accrediting body
Undergraduate
Postgraduate
Postgraduate
Notes about the row headings.
Full title of the course: Please give the full title of your
degree exactly as shown on the degree certificate,
including such descriptions as Joint Honours or
Combined Studies.
Clinical Psychology Application Form 2012
Degree and grade obtained: Please give the abbreviated
title of your degree with your honours classification, for
example, BA 2(1) Hons, MPsychSc, PhD
Type of study and assessment method: Full time/part
time/distance learning, Show whether your degree
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involved course work, empirical research, or some
combination, and how it was assessed for example:
Course work and examination
60% course and exam, 40% thesis
Research and thesis
Course work and continuous assessment
C. UNDERGRADUATE QUALIFICATION IN PSYCHOLOGY
Indicate below how you see your education/training in psychology as meeting the
requirements in relation to some or all of the following components. The components are
in accord with the Psychological Society of Ireland (PsSI) Guidelines on the
Accreditation of Courses Leading to a First Qualification in Psychology.
a.
include only courses in psychology (generally courses presented in
psychology departments or by suitably qualified psychologists);
b.
indicate clearly which courses were taken at an advanced level; and
c.
include cross-references to the supporting documentation you have submitted,
e.g. the course code from your official transcripts
Component
Biological Bases of Behaviour
Information from applicant
Transcript course
reference number
Required component
Include areas such as: Neuropsychology,
Physiological Psychology, Behaviour
Analysis, and Animal Behaviour
Developmental Psychology
Required component
Include areas such as: Child Psychology,
Adolescence, Adulthood & Ageing, and
Lifespan Development.
Cognitive Psychology
Required Component
Include areas such as:
Perception, Memory, Thinking and
Artificial Intelligence
Social Psychology
Required Component
Include areas such as:
Group Behaviour, and Organisational
Psychology
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C. UNDERGRADUATE QUALIFICATION IN PSYCHOLOGY continued
Component
Information from applicant
Transcript course
reference number
Personality and Individual
Differences
Required component
Include areas such as:
Personality Theory, and psychoanalysis.
Research Methods
Essential component
Include areas such as: Research Design,
Psychological Statistics, Qualitative
Methods, and Survey Methods.
Research Project
Specify any independent research and
name of supervisor
Applied Psychology
Include areas such as: Psychology of
Disability and Rehabilitation,
Educational, Clinical, Health, Industrial,
and Forensic Psychology
Other Areas of Psychology
Include areas such as: History of
Psychology, Environmental, Crosscultural Psychology, Theories of
Psychology, and Professional Ethics
Communication and Interpersonal
Skills
Include areas such as: Interviewing
Techniques, Social Skills Training,
Small Group Processes.
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D. POSTGRADUATE QUALIFICATION IN CLINICAL PSYCHOLOGY
Full title of postgraduate training course:__________________________ From: _____________ to:______________ (insert month and
year)
Year 1 _____weeks Year 2_____weeks Year 3_____weeks Year 4______weeks Year 5_____weeks.
Proportion of total course time allocated to clinical placement experience_______%; to academic teaching_______%
Please give details of supervised placements during your professional training course
1.
Placement setting
(full name and address of
each placement)
Adult Mental Health
2.
Child and Adolescent
Mental Health
3.
Intellectual Disability
4.
Specialist Placement
Age ranges
Dates
from/to
Total
Number of
placement
days
Frequency of
supervision
5.
6.
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Name & position of
supervisor
Method of
assessment
1. PLACEMENTS DURING TRAINING
Please provide details, for each placement outlined on previous page(s), of supervised
training experience and skill development in the areas of a) assessment, b)
formulation, c) written & oral communication, d) therapeutic models used, e) indirect
work, f) multi-disciplinary contact, g) intervention and h) evaluation.
Adult Mental Health
Child and Adolescent Mental Health
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Intellectual Disability
Specialist Placement
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2. RANGE OF PRESENTING PROBLEMS
Please describe the range of presenting problems encountered in each placement.
Placement type
Presenting problems
Adult Mental Health
Child and Adolescent
Mental Health
Intellectual Disability
Specialist Placement
3. THERAPEUTIC MODELS
What were the dominant therapeutic models taught and practised on your course?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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4. ACADEMIC PROGRAMME
Please describe the main topic areas covered including client groups; presenting
problems, assessment, formulation, intervention, research methods & statistics,
service based issues, professional/ethical issues and social/cultural issues. Cross
reference by giving the course number or code from your official transcripts.
Year 1
Year 2
Year 3
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5. ACADEMIC ASSESSMENT
Please give details of the academic work you submitted during training (indicate
whether each piece was a case study, essay, research project, presentation or
written/oral exam, thesis).
Title of work
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Description and approximate word count
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6. THESIS
Applicant should supply the a) official abstract and b) a structured summary of the
thesis of 250 to 400 words in length using the guidelines below.
Please provide:
 The thesis title, number of words, and date examined
 Names of examiners and degree for which the thesis was presented
 Objectives: State the objective of the research and the main hypotheses or questions
addressed.
 Design: Describe the design specifying the number of groups studied, and the number of
occasions on which data were collected from these groups.
 Methods: State if quantitative or qualitative methods were used. Specify the number and
characteristics of participants; the assessment instruments, psychological tests or special
apparatus used; and the procedures followed during data collection.
 Results: Give the main results. Numerical data may be given briefly.
 Data analysis: State the way qualitative data were processed or the statistics used to
analyse quantitative data.
 Conclusions: State the conclusions from the research and the implications of these for
clinical practice, policy development and further research.
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7. EXPERIENCE OF TEACHING/TRAINING/GIVING PRESENTATIONS
DURING TRAINING
Topic
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Audience
Date
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E. SUPERVISED CLINICAL PSYCHOLOGY EXPERIENCE
It is recognised that training structures differ across countries. Work experience supervised by a clinical psychologist, gained after formal
postgraduate training may be considered in meeting the requirements in regard to clinical placements.
Please give details of the work experience you have obtained under the supervision of a clinical psychologist. (If the spaces provided are
insufficient please photocopy this page to accommodate additional information and attach the photocopied page to your application.)
Work experience
(name and address)
1.
Client group
and age ranges
Dates
from/to
Number of
days
Frequency of
supervision
2.
3.
4.
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Name and position
of supervisor
Method of
assessment
1. PRESENTING PROBLEMS
Please describe the range of presenting problems encountered in each area of
supervised work experience post qualification.
Supervised Work Experience
1.
Presenting Problems/Age ranges
2.
3.
4.
2. THERAPEUTIC MODELS
What were the dominant therapeutic models taught and practised during your
supervised clinical experience?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. EXPERIENCE OF TEACHING/TRAINING/GIVING PRESENTATIONS
DURING SUPERVISED CLINICAL EXPERIENCE
Topic
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Audience
Date
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F. EMPLOYMENT AS A PSYCHOLOGIST
(If shortfalls in your academic qualifications are identified, post-qualification professional experience of the applicant must be considered so it is important that you provide
complete information on your post qualification work experience as a practising psychologist)
Job title
Service name/client
group
Address
Dates
from/to
Hours
per
week
Main duties
Note: Job title (or occupation): Indicate with a bracket or in some other way any appointments you have held (or hold) concurrently.
Dates from/to: Give month and year. It will be assumed that you are not working as a psychologist during any period not accounted for in your employment
record.
(If the spaces provided are insufficient please photocopy this page to accommodate additional information and attach the photocopied page to
your application.)
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G. ADDITIONAL INFORMATION
State here any other information you feel is needed to support your application.
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H. REFEREES
The Minister for Health is the Competent Authority for the assessment of psychology
qualifications and is advised by Psychological Society of Ireland (PsSI). Either body may seek
verification of the information provided by the applicant in relation to either professional
training or subsequent professional experience.
You should identify two (2) referees – one for each area and ask that they each complete (in
typed script) and sign the form overleaf. Appropriate referees would include the course coordinator or supervisor(s) during your professional training or senior psychologist(s) from your
current or most recent employment.
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FOR COMPLETION BY REFEREE 1
THE DoH/PsSI RESERVES THE RIGHT TO CONTACT REFEREES DIRECTLY
The applicant is applying for recognition of professional qualifications in clinical psychology
obtained outside of Ireland (Republic of Ireland) in order to work as a clinical psychologist in
the health service in the Republic of Ireland.
The Department of Health and/or the PsSI may seek verification from you of the information
provided by the applicant in relation to either professional training or subsequent professional
experience.
Please complete in typed script and then sign and stamp.
1. Name: _______________________________________________________
2. Official job title/position:_______________________________________
3. Work address:
____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________________
4. Email address: _____________________________________
5. Telephone number: _________________________________
6. Nature of contact during training/work experience/employment:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
________________________________________________
7. Referees should indicate their status within the psychological society of their own country:
Name of psychological society: ________________________________________
Status: ______________________________________________________________
Signed: _________________________________ Date: _____________________
Stamp of institution/service
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FOR COMPLETION BY REFEREE 2
THE DoH/PsSI RESERVES THE RIGHT TO CONTACT REFEREES DIRECTLY
The applicant is applying for recognition of professional qualifications in clinical psychology
obtained outside of Ireland (Republic of Ireland) in order to work as a clinical psychologist in
the health service in the Republic of Ireland.
The Department of Health and/or the PsSI may seek verification from you of the information
provided by the applicant in relation to either professional training or subsequent professional
experience.
Please complete in typed script and then sign and stamp.
1. Name: _______________________________________________________
2. Official job title/position:_______________________________________
3. Work address:
____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________________
4. Email address: _____________________________________
5. Telephone number: _________________________________
6. Nature of contact during training/work experience/employment:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
________________________________________________
7. Referees should indicate their status within the psychological society of their own country:
Name of Psychological Society: ________________________________________
Status: ______________________________________________________________
Signed: _________________________________ Date: _____________________
Stamp of institution/service
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I. EVIDENCE OF QUALIFICATION
Please list below the evidence you have enclosed which shows that your qualifications entitle
you to practice as a psychologist in the country in which your qualification was obtained. If
your registration or licence specifies an area of practice, for example, Clinical Psychology,
please include this.
1.
2.
3.
Please label each supporting document clearly
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J. DECLARATION
Any recognition granted on the basis of fraudulent or falsified information, material
misrepresentation or misstatement designed to mislead shall be invalid. The onus for ensuring
the full and accurate disclosure of information rests with the applicant.
●
I declare that the information given in this document and in all attached forms is true
and accurate.
●
I declare that I have not made a previous application for validation/recognition as a
psychologist in Ireland

I declare that I am eligible to practise as a psychologist in my home country.
●
I declare that I have not been found guilty by any statutory registration/licensing body
or professional body having jurisdiction in the matter of any professional misconduct
within the scope of my profession as a psychologist resulting in the imposition of any
suspension, fine, penalty or disciplinary measure.
●
I declare that, subject to my qualifications being recognised, I am fit to practise as a
psychologist in Ireland.
●
I understand that failure to disclose full information, or any deliberate
misrepresentation of information, is a serious matter and will invalidate my application.

I understand that I may be required to submit further documentary evidence in support
of any particulars given by me on my application form.

I understand that any false, misleading or incomplete information submitted by me
will result in the revocation of the recognition of my qualifications.
●
I agree to notify the Department of Health in writing, of any change of personal details,
e.g. change of surname or address, as and when any such changes occur.
Note: Failure to sign the application form will render it invalid
Name of Applicant: __________________________________________
(block capitals)
Signature of Applicant:___________________________________________
Date:
___________________________________________
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COMPLETED APPLICATION FORMS, SUPPORTING DOCUMENTATION AND
SCRUTINY FEE
BEFORE SUBMITTING YOUR APPLICATION PLEASE ENSURE THAT ALL OF
THE FOLLOWING CONDITIONS HAVE BEEN MET
 All relevant sections of the application form must be completed in typed text and
the form must be signed by the applicant.
 All required documentation must be enclosed and clearly referenced to the
appropriate section of the application form (incomplete applications may result in
an incomplete assessment of your qualifications/work experience).
 Do not enclose original documentation.
 All supporting documentation must be witnessed as true copies of the originals.
 If documents are provided in any language except English, authenticated
translations must be supplied in addition to a true copy of the original.
 Application forms and supporting documentation must be in loose-leaf or as
stapled pages; they should not be bound or in cellophane folders.
 2 copies of all documentation (i.e. the application form and all supporting
documentation) must be provided.
 The scrutiny fee of €500 (cheque, postal order or bank draft) made payable to the
Psychological Society of Ireland and drawn on an Irish Bank must be submitted
with the completed application.
Applications should be sent to:
Validation Unit
Department of Health
Hawkins House
Dublin 2
IRELAND
Notes:
1. The Department of Health is the Competent Authority for the assessment of psychology
qualifications and is advised by the Expert Validation Committee (EVC) of the
Psychological Society of Ireland (PSI). The Department of Health may contact an
applicant during the process. The formal decision will issue from the Department of
Health on behalf of the Minister for Health.
2. Recognition of professional qualifications is not to be regarded as an endorsement or a
declaration of the applicant’s suitability for employment in any particular post, which
is a separate matter for assessment by the employer in the normal way in accordance
with the prescribed selection criteria.
3. We recommend that you keep a full record of your application. The Department of
Health cannot accept responsibility for any loss that may occur. It will retain
documentation on file and cannot photocopy documentation for applicants.
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