UNIVERSITY OF THE WESTERN CAPE
PSYCHOLOGY DEPARTMENT
M.Psych Programme
Application Form for Clinical Psychology
2015
PLEASE NOTE: You are required to submit a typed hard copy of this completed Application
Form. The typing must be of a good enough quality for photocopying. (Font size
12,Times New Roman).
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Please ensure that your application is complete and detailed.
The application form as well as the referees' reports must reach us by the closing date:
13 June 2014 (12h00).
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Incomplete and late applications will not be considered. It is your responsibility
to keep contact with your referees to ensure that your referee reports are
submitted on time.
The summary page included must be completed in full, in black ink and printed
legibly, so that clear copies can be made.
Give all the information asked for - do not refer to your CV or other documents,
though these may be included.
Submit one hard copy.
Please do not staple the documents together since they will have to be separated
again.
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Students who are currently doing their Honours in Psychology, whose marks will
not be available before December 2014, will not be eligible to apply for the
M.Psych (Clinical Psychology) Programme for 2015.
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Please return completed application forms to:
M.Psych Programme Coordinator
Department of Psychology
University of the Western Cape
Private Bag X17
BELLVILLE
7535
SOUTH AFRICA
Phone: (021) 959-2453
Fax:
Enquiries:
021 -959 3515
Lito Daniels: (021) 959-3093
E-mail: ledaniels@uwc.ac.za
Erica Munnik: (021) 959-2835
E-mail: emunnik@uwc.ac.za
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Affix Photo
PERSONAL DETAILS
Surname:
First Names:
Name you are known by:
Residential Address:
Applicable address where you may be contacted:
Telephone No(s):
Cell:
Fax:
E-mail:
Sex:
Date of birth and age: D.O.B
Age:
Relationship status:
Do you have any dependants? Give details:
Present work/study situation. Give details:
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1.
*
*
Academic record
Please include an official statement of all your academic results. If you are
completing your Honours/ B.Psych or 4-year equivalent degree this year, also enclose
an official progress report, indicating your specific level of performance (%) in the
various modules as well as your overall percentage in the June examination.
If you have completed a Honours/ B.Psych or 4 year equivalent degree be sure to
indicate all the modules completed and the percentages obtained for each, as well as
your overall percentage for the degree.
In addition to official transcripts to be attached, please complete 1.1 and 1.2 in detail.
Please include only postgraduate and undergraduate Psychology modules, as
well as the average percentages obtained for Honours and undergraduate
psychology studies.
NB. Your application cannot be considered in the absence of these details.
1 HONOURS
Year
Name of institution
Course
Subjects
AVERAGE HONOURS MARK
4
% Obtained
Have you completed honours modules in:
Module
Psychopathology
Psychometry
Personality theory
Research
Counselling skills
Hons./B. Psych. Internship?
Where? ______________
Internship completed?
Yes/ No
Foreign students:
Yes/No
Have you obtained a foreign qualification?
Has it been SAQA assessed?
Has it been SAQA approved?
Do you have SA residency?
(Please submit relevant documentation)
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2 UNDERGRADUATE PSYCHOLOGY MODULES
Year
Name of institution
Course
Subjects
AVERAGE UNDERGRADUATE PSYCHOLOGY
MARK
6
% Obtained
3.
ADDITIONAL TRAINING
Indicate whether you have received additional training relevant to psychology,
apart from your formal university training.
Where?
4.
When?
What?
OCCUPATIONAL EXPERIENCE.
Give details of your position, the type of work, whether full or part-time,
voluntary, etc.
Year
Position/Type of work
Part-time
Full-time
Voluntary
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5.
Briefly describe how psychological theory influences your understanding of the
world. (Maximum 100 words)
6
What are your views on the role of psychology in South Africa and on the
African continent? (Maximum 100 words)
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7
What motivates you to follow a career in psychology, and in what type of setting
would you prefer to work? (Maximum 100 words)
8.
Have you occupied any positions of leadership, service or influence, and how has
this prepared you for a career in psychology.
___________________________________________________________________________
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9.
Describe some of the relationships that are important to you. Who provides you
with emotional support? If selected, how would these relationships and support
be impacted?
10.
Referee reports: List the referees that you approached.
Name of referee
Contact detail
Relationship (e.g. lecturer,
priest)
11. Rate (GOOD, AVERAGE, or POOR) your proficiency in the following languages:
LANGUAGE
READING
WRITING
English
Afrikaans
Xhosa
Other SA:
Specify:
Other
Specify:
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UNDERSTANDING
12.
Do you have any disability that may impact on your training:
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Medical history: mention relevant conditions, incidents, etc.
14.
Psychological history. Mention both negatives and positives.
15.
How are you planning to fund your studies, if selected?
16.
Any other relevant information:
I hereby declare that the above information is correct.
Signed:
Date:
______________________
__________________________
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Write an autobiographical essay of one typed page only, including details of your
personality, personal history and relationships as well as a reflection on why you want
to become a Clinical Psychologist. The typing must be of a good enough quality for
photocopying. ( Font size 12,Times New Roman, maximum 1000 words).
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