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CAPIC Agency Application

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					                                       CAPIC Agency Application



GENERAL INFORMATION

1). Agency Name:       _____________________________________________________________

2). Date of Last Update:                       3). CAPIC Member Since:       ___________________

4). CAPIC Member Status:          Full-Time Internship      Half-Time Internship

5).   Funded          Unfunded

6). Agency Type: (Check one)
       Armed Forces Medical Center                               Private General Hospital
       Child/Adolescent Psychiatric or Pediatrics                Private Psychiatric Hospital
       Community Mental Health Center                            State and/or County Hospital
       Group of Related Medical Facilities                       University Counseling Center
       Medical School                                            Veterans Admin. Medical Center
       Prison or Other Correctional Facility                     Other-Center or Hospital

7). Types of Internships Available: (Check all that apply)
       Half-Time, 1 Year (20-24 hours/week)
       Half-Time, 2 Years (20-24 hours/week)
       Full-Time, 1 Year (35-40 hors/week)

8). Agency Name:           __________________________________________________

      Department:          _______________________

           Street:         __________________________

  City, State, Zip:        _________________

          County:                _____________

          Region:        No. Cal        So. Cal          Mid Coast     Central Valley

           Phone:                                                    _________

              Fax:                                                       ______

           E-mail:

         Website:      ___________________________________________

  Executive Director:            __________




CAPIC Agency Application                                                                           1
INTERNSHIP ADMINISTRATION

9). Director of Training (Must be a California licensed Psychologist):


                           _____________________
(title)                    (first name)       (last name)            (degree)                (CA Psychology license #)



10). Contact Name (If other than Director of Training):

NOTE: this is the person who will be sent all CAPIC official communications, and who will have access to the
Website to make changes in your on-line profiles.



(first name)                    (last name)                      (degree)               (CA license #)


Job Title of Contact Person:



11). Contact Phone:

          Contact Email:        _____



12). HISTORY OF AGENCY AS TRAINING SITE
    Year Agency established: ______

          Year Psychology Training Program established:          ____________

          Describe history of agency as training site (types and levels of training):




13). Agency budget provides for support of its Training Program:                Yes          No




CAPIC Agency Application                                                                                                 2
2008/2009 TRAINING POSITION INFORMATION

14). PREDOCTORAL PSYCHOLOGY INTERNSHIP:
                                                         # Unfunded   # Funded   Hrs/Week    Hrs/Year



Half-Time (20-24 hrs/wk) Predoctoral Internship              ____        ___          ____       ____

Full-Time (35-40 hrs/wk) Predoctoral Internship              ____        ___          ____       ____

    NOTE: total intern FTE (FT # + twice HT #) =     __________

Half-Time (20-24 hrs/wk) Stipend/Year: $

Full-Time (35-40 hrs/wk) Stipend/Year: $

        START DATE _________           END DATE      _______________



15). Required days/times trainees/interns must be present in agency:




16). Percentage of hours/week providing direct face-to-face psychological services:

                           >=25%        >=50%        >=75%



17). Details and requirements of funding and benefits:




18). Weeks of vacation per year:

    Fringe Benefits:

           Vacation                 Professional Development Leave
           Sick Leave               Library
           Holidays                 Recreational Facilities
           Health Insurance         CE Tuition
           Inservice Training       Research Time




CAPIC Agency Application                                                                                3
19). Locations where predoctoral interns perform services:

    Service Locations (check one):      Only at agency/dept/address on record
                                        At agency/dept/address on record and at following locations:
                                        Not at agency/dept/address on record but at following locations:

    Site Name(s):                                Site Address(es):

                _____________________________________________________________________________

    ________________________________________________________________________________________

    ________________________________________________________________________________________

    ________________________________________________________________________________________

    ________________________________________________________________________________________

    ________________________________________________________________________________________




20). For each training location, is there always a licensed mental health professional on site with whom
    the intern may have face-to-face contact? If NO, please explain who does on site supervision.

                Yes       No



21). OTHER PSYCHOLOGY TRAINING POSTITIONS:
                                     Number                       Hours/Week

            Postdoctoral Training:

            Practicum:



PRACTICUM TRAINING
Indicate the number of psychology practicum trainees and hours per week the program accepts for each
level:
                                                Number       Hours/Week

        First-Year Doctoral Students

        Second-Year Doctoral Students

        Third-Year Doctoral Students




CAPIC Agency Application                                                                                   4
CURRENT TRAINING COHORT
                                                                                                              Current Training
Year Number         (e.g., 2008-2009)

22a). # of Half-Time PREDOCTORAL INTERNS in current training cohort:

22b). # of Full-Time PREDOCTORAL INTERNS in current training cohort:

22c). Number of 2008/2009 Predoctoral Intern Positions Filled Listed By Doctoral Program of Enrollment:

                                              Half-Time/Full-Time                                         Half-Time/Full-Time
Adler School of Professional Psychology         _______/_____         Pacific Graduate School of Psychology      _______/_____
Adelphi University                              _______/_____         Pacifica Graduate Institute                _______/_____
Alliant/CSPP-SF                                 _______/_____         Pepperdine University                      _______/_____
Alliant/CSPP-SD                                 _______/_____         Phillips Graduate Institute                _______/_____
Alliant/CSPP-LA                                 _______/_____         The Chicago School – SC                    _______/_____
Alliant/CSPP-F                                  _______/_____         The Wright Institute                       _______/_____
Antioch-SB                                      _______/_____         University of La Verne                     _______/_____
Antioch-Seattle                                 _______/_____         Other: _____________________               _______/_____
Argosy University-Orange County                 _______/_____         Other: _____________________                _______/_____
Argosy University-SF Bay campus                 _______/_____         Other: _____________________               _______/_____
Azusa Pacific University                        _______/_____         Other: _____________________               ______/_______
California Institute of Integral Studies         _______/_____        Other: _____________________               ______/_______
Fielding Graduate Institute                      _______/_____        Other: _____________________               ______/_______
Forest Institute of Professional Psychology     _______/_____         Other: _____________________               ______/_______
Fuller Theological Institute                     _______/_____        Other: _____________________                    /
Institute of Transpersonal Psychology           _______/_____         Other: _____________________                    /
John F. Kennedy University (JFKU)               _______/_____         Other: _____________________                    /


23). Other Trainees in Current Training Program:


                 Postdoc, or Practicum                       Number
              psychology practicum
              students
              psychology postdocs

              MSW

              MFT



24). AGENCY DESCRIPTION




CAPIC Agency Application                                                                                                          5
25). AGENCY MISSION:




26). Theoretical Orientations(s) of Staff:
       Bio-psychosocial                    Narrative

       Cognitive behavioral               Psychodynamic/Psychoanalytic

       Family Systems                     Psychosocial Rehabilitation

       Humanistic/Existential             Transpersonal

       Integrative                        Other

         Jungian

Comments Regarding Theoretical Orientation of Staff:




27). AGENCY ACCESSIBILITY AND DISABILITY ISSUES

    Are you familiar with the Americans with Disabilities Act of 1990?                    Yes   No

    If not, would you like information?                                                   Yes   No

    Is the agency wheelchair accessible?                                                  Yes   No

    Do trainees have access to computers to do their paperwork?                           Yes   No

    Has there been a student/intern/trainee with a disability at the
    agency within the last five years?                                                    Yes   No

    Are there any training staff with disabilities at the agency?                         Yes   No

    Has the agency provided in-service training on disabilities in the past five years?   Yes   No


Comments on agency accessibility:




CAPIC Agency Application                                                                             6
POPULATIONS SERVED

8a). Provide a brief demographic and/or diagnostically descriptive statement about the population your
      program serves: (Note: This statement will be on your program profile)




28b). POPULATION (approximate percentages of clients in each category):
   Life Cycle %
        Children (ages 0-12)
        Adolescents (ages 13-17)
        Adults (ages 18-64)
        Families
        Elders/Seniors (>65)


    Gender %
        Female
        Male
        Transgendered


    Dysfunction Level %
        High (psychosis, severe personality disorder)
        Moderate (moderate personality disorder)
        Mild (depression, anxiety, adjustment)


    Ethnic/Cultural Identity (% = 100)
        African-American
        Asian & Asian-American
        Euro-American
        Latino/Latina
        Native American
        Bi-racial


    Other Group Identified %
        Gay/Lesbian
        Clients with disabilities
        Other (International subsets, etc.)


CAPIC Agency Application                                                                                 7
TRAINING AND EDUCATION OFFERED BY INTERNSHIP

29). Please describe your objective in training Predoctoral Interns. Please include a brief description of your
     training program and how it fits within the goals or mission of your agency.




30). If applicable, describe in detail how the internship training differs from practicum training:




CAPIC Agency Application                                                                                          8
31). RESPONSIBILITIES AND FUNCTIONS OF PREDOCTORAL INTERNS




32a). CLINICAL SERVICES (Please checkmark the clinical responsibilities of the intern):

           Brief                    Outpatient

           Long Term                Crisis

           Individual               Assessment

           Couples                  Neuropsychology

           Family                   Consultation

           Group                    Psychological Testing

           Inpatient                Other (specify):



32b). Specify Other Clinical Services Here:




RESEARCH

33) Does the internship include opportunities for research activities?   Yes       No
    Details of research opportunities:




CAPIC Agency Application                                                                  9
CASES

34). Will the intern or trainee have an opportunity to follow a case for a minimum of 6 sessions?
       Yes         No


TRAINING EXPERIENCES/OPPORTUNITIES

M=Major I=Informal/Minor/External      (check all that apply)

35). POPULATIONS
                           Infants                                   Homeless
                           Children                                  Ethnic Minorities
                           Adolescents                               Rural
                           Adults                                    Students
                           Elders/Seniors >65                        International Students
                           Outpatient                                Gay/Lesbian/Transgender
                           Low Income


36). TREATMENT MODALITIES
                     Individual Therapy                              Crisis Intervention
                     Family therapy                                  Critical Incident Debriefing
                     Couples Therapy                                 Brief Therapy
                     Group Therapy                                   Long Term Therapy
                     Community Intervention                          Case Management
                     Consultation/Liaison


37). SPECIALTY AREAS
                            Behavioral Medicine                    Pediatrics
                            Health Psychology                      Infant/Parent
                            HIV/AIDS                               School
                            Eating Disorders                       Counseling
                            Disabilities                           Vocational/Career Development
                            Assessment                             Multicultural Therapy
                            Neuropsychology                        Feminist Therapy
                            Serious Mental illness                 Primary Care
                            PTSD/Trauma                            Public Policy/Advocacy
                            Forensics                              Administration
                            Substance Abuse                        Program Evaluation
                            Sexual Offenders                       Psychopharmacology
                            Sexual Abuse                           Psychology of Men
                            Domestic Violence                      Psychology of Women
                            Geropsychology                         Death/Dying/Bereavement




CAPIC Agency Application                                                                            10
ASSESSMENT AND PSYCHOLOGICAL TESTING
38). Will the trainee have an opportunity for assessment/psychological testing experience?
         Yes       No

39). Percentage of time allowed for providing assessment services:


40). Additional supervision and training for assessment/psychological testing:                      Yes        No


41). Describe the assessment training:




42). List Assessment Supervisors:




43). INSTRUMENTS USED:

           Projective         Intelligence         Academic/Vocational

           Personality        Neuropsychological

44). Average number of test batteries completed per year:


INTERNSHIP SUPERVISION
45).                                           Half-Time           Full-Time
        INDIVIDUAL hrs/week

           GROUP hrs/week


             Supervisor Requirements

                * Primary supervisors of predoctoral internship-level students must be employed by the same
             agency at least 50% of the hours      being worked by the intern and available to the intern 100% of the
             time the intern is accruing supervised professional experience.

               * State regulations require that supervision (individual and group added together) must account for a
             minimum of 10 percent of an intern's program.

               * All primary and delegated supervisors (who count for the 10 percent rule) must be able to
             certify training in supervision as required by the Board of Psychology.

                * Refer to CAPIC membership criteria #s 3 and 4 for more information (also see criterion #7
             regarding training).




CAPIC Agency Application                                                                                                11
46). California Psychologists who can serve as Primary Supervisors: (For additional use page 17)


                                                        Hrs/Wk
 Name                             Degree    CA Lic #   Employed      Orientation




 California Psychologists who serve as Delegated Supervisors: (For additional use page 17)

                                                        Hrs/Wk
 Name                             Degree    CA Lic #   Employed      Orientation




 Board Certified Psychiatrists who serve as Delegated Supervisors:

                                                        Hrs/Wk
 Name                             Degree    CA Lic #   Employed      Orientation




 Other Licensed Mental Health Professionals with significant role in Training Program:

                                                        Hrs/Wk
 Name                             Degree    CA Lic #   Employed      Orientation




CAPIC Agency Application                                                                           12
Non-Licensed Staff with Significant role in Training Program:

 Name                              Degree Orientation




47). TOTAL COUNT OF LICENSED MENTAL HEALTH STAFF BY LICENSE:

     Number of Licensed MH Staff (not FTE)

     # Psychologists ________                    # Psychiatrists ________

     Other licensed MH staff (list discipline, (then number)

     ____________________(# =_____)              ____________________(# =_____)

     ____________________(# =_____)              ____________________(# =_____)

     ____________________(# =_____)              ____________________(# =_____)



48). DIRECT METHODS OF SUPERVISION HOURS PER YEAR:


                                             Individual         Group
        Direct Live Observation
        Reviewing of Videotapes
        Reviewing Audiotapes
        Review Session Process Notes

                                            90

ORIENTATION AND DIDACTIC TRAINING


49). ORIENTATION PROCESS

        # of Weeks                       Total Hours


        CAPIC Criterion 7:

          * FULL-TIME: The internship must provide at least four hours a week in didactic activities
        such as case conferences, seminars, in-service training or grand rounds in addition to
        individual and group supervision

          * HALF-TIME: the internship must provide at least two hours a week in didactic activities
        such as case conferences, seminars, in-service training, or grand rounds in addition to
        individual and group supervision.

CAPIC Agency Application                                                                               13
50a) DIDACTIC TRAINING - WEEKLY
                                                 Hrs/Wk            Day of Week         AM/PM




50b) DIDACTIC TRAINING - MONTHLY
                                                 Hrs/Wk            Day of Week         AM/PM




 Syllabus or Curriculum for Training Program:        Yes      No

 Reading List or Bibliography:       Yes       No


MULTICULTURAL TRAINING


   Following are a suggested set of standards on multicultural competency of supervisors in
   CAPIC Internships:

      Supervisors meet multicultural criterion (A and B):

   A. Training

   1. Didactic Training
               a. Formal training in multicultural issues in terms of credit hours; and
               b. Clinical supervision over a time period, i.e., hours, by an expert in multicultural
                  issues, as supervised in an internship and/or post graduate supervision.

           2. Formal recognition of Multicultural Training
              a. Contributors to the field
              b. Recognition by receiving a certificate of expertise

   B. Experience in the targeted community:

              1. Currently practicing in a targeted community
              2. Institutional and/or group involvement in the community
              3. Ability to exercise community and institutional interventions




CAPIC Agency Application                                                                                14
51a). Describe opportunities for multicultural training:




51b). Number of Supervisors that are multilingual in language(s) used by populations served by agency:



51c). Languages (or specific dialects) staff can use in the delivery of clinical service:




APPLICATION PROCESS
52). APPLICATION DEADLINE: (Leave Blank - CAPIC Members agree to adhere to CAPIC deadline)


53a). # of Predoctoral internship applicants in current training year:              Training Year:   20______

53b). # of Predoctoral internship placements in current training year:


54). Please specify your application procedure:




55). REQUIRED FOR INTERN APPLICATION (in addition to CAPIC UNIFORM APPLICATION):
          Curriculum Vitae                                 Experience (list below)

            Letters of Recommendation (how many)                         Letter of Readiness

            Supplement Application Form (please attach)         Other (indicate below)

            Letter of intent (please indicate content below)

            Transcripts - Graduate

            Transcripts - Undergraduate

            Specify Course Work (list below)




CAPIC Agency Application                                                                                        15
56). Required/Desired Experience (e.g., specific populations, testing, etc):




57). Letter of intent content:




58). Specific Coursework (e.g., Neuropsychology, child Development, etc):
     Indicate if coursework is required or preferred below:


                                                Required       Preferred
                                                Required       Preferred
                                                Required       Preferred
                                                Required       Preferred

59). Please briefly describe the clinical and educational experience necessary to be considered for
     acceptance into your training program:




60). Describe the interview process for your agency (individual or group interview, role playing required,
     case presentation required, etc):




61). Describe what you are looking for in an applicant:




CAPIC Agency Application                                                                                     16
62). Other information not covered above:




63). Indicate the number of prospective interns who applied last year:


64). Please briefly note any additional comments about the application process here:




65). Use this space for additional information. Please indicate the corresponding page and question prior
     to notation, if applicable.




66). Please attach your current training handbook, syllabus, reading list, brochures, website materials,
     calendar, and other printed information concerning the services and training program available at your
     agency.

    On file at CAPIC?       Yes       No



67). Please attach the agency’s formalized written due process/grievance procedures which includes
     notice, hearing, and appeal processes for interns.

        On file at CAPIC?       Yes        No



68). Is office space available for trainees?    Yes     No               If yes, please describe below:




CAPIC Agency Application                                                                                      17
69). Is your program accredited by the American Psychological Association?        Yes      No

    If yes, what is the status of your accreditation?




70). Is your training program a current member of the Association of Predoctoral and postdoctoral
     Internship centers (APPIC)?       Yes    No




71). Do you have concerns about the stability of your agency and/or training program?     Yes       No

    If yes, please explain:




72). Does your agency agree to adhere to the timetables, policies and procedures of the CAPIC
     application/selection process?   Yes       No




    I verify that this information is current and accurate.




        Updated By (Name of Agency Representative)                     Update Completion Date




        Submit application online with payment by credit card.   (NO PAYMENT DUE FOR UPDATES)




CAPIC Agency Application                                                                                 18

				
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