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PASEO Program
Thank you for showing an interest in the PASEO program!
Please complete the following form to the best of your ability.
I.Personal details
Name
Nationality
Date of birth
Current Address
Phone
Email
For students:
Name of Institut ion
Department
Degree sought (e.g. PhD, PsyD,
MSW, MD)
Year in program
Program director (name and
contact information)
Academic advisor (name and
contact information)
For professionals:
Degree
Graduate institution
Present position (title,
department, location)
All applicants:
Relevant courses or trainings/seminars completed
Two professional references (name, contact
information)
Name:
Contact number:
Email:
Relationship:
:
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Name:
Contact number:
Email:
Relationship:
Speaking
Beginner-Intermediate
Intermediate
Intermediate-Advanced
Can engage in basic
conversation with young
children. Can use
“survival” language (e.g.
know how to ask for
directions, say where
from, describe basic
medical concerns).
Can engage in basic
conversation with adults,
can speak about familiar
topics (profession,
family, interests) fairly
comfortably.
Feel confident carrying out
social conversat ion and
familiar work tasks. May
make some tense errors
and have difficulty with
more “academic”
conversations.
Professionally, can
communicate basic
information to client
“Soy la terepeuta”, “Su
cita es a las 9:00”
Writing
Can write lists, short
messages, and simple
notes. Writing is
conversational,
informal, and mostly
uses present tense. Basic
errors in grammar, word
choice, and spelling
likely.
Professionally, may be
able to compose simple
letters to clients that
require minimal edit ing.
Listening
Comprehension
Can understand
sentence-length speech
in basic personal and
social contexts,
especially in situations
where information is
repeated or habitual.
Professionally, may be
able to understand and
transcribe basic personal
information of clients
(address, phone number,
names, etc.)
Professionally, can
communicate basic
instructions and
education with clients
and do basic scheduling
or administrative tasks.
Can write to meet
practical needs, such as
messages, notes, and
requests for information.
Professionally, can
compose basic letters to
clients (e.g. about
appointment time/place)
and create simple
worksheets for clients
(e.g. goal tracking,
thought records, etc.).
Easily understand
information in basic
social and personal
contexts.
Comprehension
improved with familiar
people or settings. Rely
heavily on context clues
Can engage in structured
clinical activities that are
very familiar or when
correct responses are
provided in manuals.
Professionally, can conduct
clinical interviews, translate
instructions for tests, and
work with families with
varying levels of English
Can meet basic
work/academic writ ing
needs and compose
paragraphs on familiar
information. Rely on
writ ing style of first
language; leads to some
awkward phrasing.
Professionally, can create
behavior plans, goal sheets,
and report summaries with
relative accuracy but lack
technical fluency
Consistently understand
instructions, anecdotes,
and news stories. Have
difficulty with different
dialects, regions, and slang.
Professionally, can work
with patients in structured
clinical activities
(diagnostic interviews,
psychological assessments);
difficulty with unstructured
therapy
Advanced
Can discuss situations in a
time frames (past, presen
future, imperfect) with eas
and utilize idioms, slang,
and technical language.
Speech has good flow, is
spontaneous, and is not
limited by topic
Professionally, can provide
a broad range of clinical
services in Spanish (e.g.
therapy, test ing, and
diagnostic interviewing.
Write rout ine informal and
formal correspondence.
Can create effective
summaries of information
and write extensively on
topics of interest.
Professionally, can write
professional (psychologica
reports, treatment plans
and goals, and
psychoeducational materi
for patients
Understand with ease
social/personal narratives
and factual lectures in one
field. Good understanding
of complex (academic)
presentations across topic
Professionally, near fluent
comprehension of client
concerns at both a surface
and deeper “meaning”
level. May be unfamiliar
with slang/dialectical
differences
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Reading
Can read and
comprehend children’s
books and information
for social/survival
purposes (e.g. menus,
basic personal forms).
Professionally, can
understand most
information from intake
forms
Can read young adult
novels and most
social/personal texts (e.g.
magazines, information
forms)
Professionally, can
comprehend intakes
completed by clients and
understand gist of
psychological reports
Can understand news
stories, fiction at young
adult reading level, and
many field-specific texts.
Professionally, can
comprehend summaries,
reports, and case studies.
Understand information in
Spanish designed for
parents or patients
Can read and understand
most novels as well as
complex reports/articles in
one’s field. Professionally
can read college-level text
in education or other
familiar subjects, easily
understand psychological
reports or case description
Professionally, can read
college-level texts in
education or other familia
subjects, easily understand
psychological reports or
case descript ions
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Speaking
Beginner-Intermediate
Intermediate
Intermediate-Advanced
Can engage in basic
conversation with young
children. Can use
“survival” language (e.g.
know how to ask for
directions, say where
from, describe basic
medical concerns).
Can engage in basic
conversation with adults,
can speak about familiar
topics (profession,
family, interests) fairly
comfortably.
Feel confident carrying out
social conversat ion and
familiar work tasks. May
make some tense errors
and have difficulty with
more “academic”
conversations.
Professionally, can
communicate basic
information to client
“Soy la terepeuta”, “Su
cita es a las 9:00”
Writing
Can write lists, short
messages, and simple
notes. Writing is
conversational,
informal, and mostly
uses present tense. Basic
errors in grammar, word
choice, and spelling
likely.
Professionally, may be
able to compose simple
letters to clients that
require minimal edit ing.
Listening
Comprehension
Can understand
sentence-length speech
in basic personal and
social contexts,
especially in situations
where information is
repeated or habitual.
Professionally, may be
able to understand and
transcribe basic personal
information of clients
(address, phone number,
names, etc.)
Reading
Can read and
comprehend children’s
books and information
for social/survival
purposes (e.g. menus,
Professionally, can
communicate basic
instructions and
education with clients
and do basic scheduling
or administrative tasks.
Can write to meet
practical needs, such as
messages, notes, and
requests for information.
Professionally, can
compose basic letters to
clients (e.g. about
appointment time/place)
and create simple
worksheets for clients
(e.g. goal tracking,
thought records, etc.).
Easily understand
information in basic
social and personal
contexts.
Comprehension
improved with familiar
people or settings. Rely
heavily on context clues
Can engage in structured
clinical activities that are
very familiar or when
correct responses are
provided in manuals.
Can read young adult
novels and most
social/personal texts (e.g.
magazines, information
forms)
Professionally, can conduct
clinical interviews, translate
instructions for tests, and
work with families with
varying levels of English
Can meet basic
work/academic writ ing
needs and compose
paragraphs on familiar
information. Rely on
writ ing style of first
language; leads to some
awkward phrasing.
Professionally, can create
behavior plans, goal sheets,
and report summaries with
relative accuracy but lack
technical fluency
Consistently understand
instructions, anecdotes,
and news stories. Have
difficulty with different
dialects, regions, and slang.
Professionally, can work
with patients in structured
clinical activities
(diagnostic interviews,
psychological assessments);
difficulty with unstructured
therapy
Can understand news
stories, fiction at young
adult reading level, and
many field-specific texts.
Professionally, can
Advanced
Can discuss situations in a
time frames (past, presen
future, imperfect) with eas
and utilize idioms, slang,
and technical language.
Speech has good flow, is
spontaneous, and is not
limited by topic
Professionally, can provide
a broad range of clinical
services in Spanish (e.g.
therapy, test ing, and
diagnostic interviewing.
Write rout ine informal and
formal correspondence.
Can create effective
summaries of information
and write extensively on
topics of interest.
Professionally, can write
professional (psychologica
reports, treatment plans
and goals, and
psychoeducational materi
for patients
Understand with ease
social/personal narratives
and factual lectures in one
field. Good understanding
of complex (academic)
presentations across topic
Professionally, near fluent
comprehension of client
concerns at both a surface
and deeper “meaning”
level. May be unfamiliar
with slang/dialectical
differences
Can read and understand
most novels as well as
complex reports/articles in
one’s field. Professionally
can read college-level text
in education or other
© Brieanne Kohrt, PhD, 2014
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basic personal forms).
Professionally, can
understand most
information from intake
forms
Professionally, can
comprehend intakes
completed by clients and
understand gist of
psychological reports
comprehend summaries,
reports, and case studies.
Understand information in
Spanish designed for
parents or patients
familiar subjects, easily
understand psychological
reports or case description
Professionally, can read
college-level texts in
education or other familia
subjects, easily understand
psychological reports or
case descript ions
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II.
Spanish Competency: Use the following table to estimate your level of proficiency
for speaking
Beginner-Intermediate
Intermediate
Intermediate-Advanced
Advanced
Speaking
[ ]
[ ]
[ ]
[ ]
Writing
[ ]
[ ]
[ ]
[ ]
Listening
[ ]
[ ]
[ ]
[ ]
Reading
[ ]
[ ]
[ ]
[ ]
[ ]
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Beginner-Intermediate
Intermediate
Intermediate-Advanced
Advanced
Speaking
[ ]
[ ]
[ ]
[ ]
Writing
[ ]
[ ]
[ ]
[ ]
Listening
[ ]
[ ]
[ ]
[ ]
Reading
[ ]
[ ]
[ ]
[ ]
[ ]
© Brieanne Kohrt, PhD, 2014
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1. Based on the table above, please provide your best estimate of your Spanish
language ability:
2. List and briefly describe the professional activities that you have conducted in
Spanish
III.Program Interests and Previous Experience: Please respond to the following two questions
in no more than 300 words (per question)
1. Describe your motivations for being interested in this program. What experiences
have you had that led to your interest in Latino mental health and/or global mental
health? What do you hope to achieve by attending this program?
2.
Describe your past experiences working within the Latino community and
any past experiences abroad (including working, volunteering, study, or meaningful
travel experiences). How have these experiences shaped your Spanish language
development? What do you see as existing gaps in your linguistic and professional
abilities in Spanish?
3. Additional comments: (Nothing is required here, but feel free to use this space to share any
other information about yourself/your experiences that might be helpful to your application)
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IV.Program Preferences: Please indicate your needs/preferences in the following areas. Note
that responses have no bearing on being accepted into the program, but help us in
tailoring the experience and providing the necessary resources to meet your needs
4. Preferred dates
for training: Please
indicate which date
you would like to
attend the program.
If you are available
for more than one
date,
indicate
preferences
with
numbers (e.g. 1 next
to first choice, 2 next
to second choice). All
dates are for the year
2015.
Three-week program
[ ] Jan. 4th -24th
[ ] May 10th-May 30th
[ ] July 5th-July 25th
Six-week program
[ ] Jan. 4th- Feb 14th
[ ] May 10th - June 20th
[ ] July 5th- Aug 15th
5. Housing
preferences: Please
rank
housing
preferences below. If
you
would
not
consider a given
option, do not rank
it. If you have special
circumstances that
require
a
given
option,
briefly
explain those below.
[
] Volunteer
house
[ ]
Homestay
[
] Individual/family
housing
*Special circumstances:
_____________________
_____________________
_____________________
________
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6. Please indicate
any
programs/activities
at SKIP that you are
particularly
interested in
helping with as part
of the service
learning component
of the program:
[ ] Primary school classroom
[ ] Music
[ ] Economic development
[ ] High school classroom
[ ] Art
[ ] Youth work (mentoring)
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[ ] English class
7. What special
training, skills, or
interests do you
have that you
would hope to
utilize in the
service-learning
component of
PASEO?
8. Please list any
certifications you
have or relevant
training you have
completed (e.g.
first aid training,
CPR, professional
certifications)
9. Do you have any
health issues that
you would like us to
be aware of?
10. Do you have any
dietary restrictions
or preferences? (e.g.
lactose or gluten
allergy; vegetarian)
[ ] Computer/IT class
[ ] Communications
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11. In order for us to
develop our
recruitment
process, it is really
helpful for us to
know how people
find out about the
PASEO program
and/or SKIP. Please
let us know how
you heard about our
program.
V.Formal Disclosure: This position involves working with vulnerable people and so we need to
know if you have any criminal convictions. A past conviction will not necessarily prevent
you from volunteering. SKIP reserves the right to check your criminal record, signing this
document will act as consent for us to contact the relevant agencies in your area if we
wish.
Have you ever been convicted of any criminal offence?
[ ] YES
[ ] NO
If yes then please provide details below:
VI.Submission Instructions: Please sign and scan this application as well as the following
materials to Brieanne Kohrt, PhD, at PASEOLLC@gmail.com If you do not have access to a
scanner, you can leave the signature space blank and application will be signed upon
acceptance to the program. Please send materials in one e-mail.
1) Completed application (Please name your file LAST NAME_PASEOapp)
2) Current curriculum vitae
Application deadlines are as follows:
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Cycle
Dates of Program
Application Deadline
1
January/February 2015
10/1/2014
2
May/June 2015
2/1/2015
3
July/August 2015
4/1/2015
VII.Affidavit: The information given is an honest portrayal of my interests and abilities and the
information provided above is correct to the best of my knowledge. I understand that
deliberate misrepresentation or omission of factual information requested may prevent me
volunteering for SKIP or being admitted to the PASEO program.
Signature: _______________________________________
______________
Date: