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Clinical Psychology Doctoral Program - Clinical Training Office
Statement of Readiness for APPIC/APA Application
This form provides the Director of Clinical Training with the necessary information to complete the Academic Program’s
Verification of Internship Eligibility and Readiness (AAPI Part 2). Failure to obtain all of the required signatures may delay a
student’s internship application process.
Student Name:
Date:
Part I: To be filled out by the Registrar’s Office.
1. Did the student receive a B or above in the following courses? (IP = In Progress)
a. Case Consultation I (PSY 685)
Yes
b. Case Consultation II (PSY 686)
Yes
c. Case Consultation III (PSY 687)
Yes
d. Family Systems Interventions (PSY 740)
Yes
e. Cognitive-Behavioral Therapy (PSY 741)
Yes
f. Child and Adolescent Interventions (PSY 743)
Yes
g. Group Therapy (PSY 681)
Yes
h. Psychodynamic Interventions (PSY 742)
Yes
i. Couples Interventions (PSY 744)
Yes
2. Student’s cumulative PGI GPA is __________.
3. Did the student pass the Comprehensive Exam?
4. Student currently has _____ incompletes on his/her transcript.
5. Are there any complaints currently pending against this student?
If yes, please describe here:
No
No
No
No
No
No
No
No
No
6. Were any complaints filed in the past and found to be legitimate?
If yes, please describe here:
IP
IP
IP
IP
IP
IP
IP
IP
IP
Not taken yet
Not taken yet
Not taken yet
Not taken yet
Not taken yet
Not taken yet
Not taken yet
Not taken yet
Not taken yet
Yes
No
Yes
No
Yes
No
Registrar Signature
Date
Part II: To be filled out by the Clinical Training Office Coordinator.
The student received _____ acceptable _____ unacceptable ratings on the Professional Behavior Evaluation Form.
The student received the following Global Assessment and Review ratings:
Professional Behavior _____
Relationship
_____
Assessment
_____
Intervention
Clinical Training Office Coordinator
_____
Date
Part III: To be filled out by the Clinical Training Office Coordinator:
The student will have successfully completed two practicum rotations by the time he/she begins an internship placement.
Hours through October 31, 2008
Hours estimated after November 1, 2008
Intervention & Assessment
Support Hours
Supervision
Intervention & Assessment
Support Hours
Supervision
Clinical Training Office Coordinator
Date
Comments:
Revised 6/2/08