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					CALIFORNIA PSYCHOLOGY INTERNSHI P COUNCIL                                                      C   A   P   I   C

                                                           Promoting Excellence in Professional Psychology

                                   CAPIC Uniform Application (CUA)
                                                         (revised 11/20/2010)

Please complete this form and send it directly to the agencies to which you wish to apply. Note that many of the
fields below are drop-down menus, and others allow you to type in as much information as you need.
A complete internship application includes: (sites may request materials to be sent separately)
     CAPIC Uniform Application (CUA)
     Cover letter / Letter of interest
     Curriculum vita
     CAPIC Eligibility and Readiness Form (CERF), signed by your Training Director
     3 Letters of recommendation
     Additional site-specific application materials, if requested

Personal Information

Name:                            Degree (if any):

Home Address:                                                                         Email:

Phone: Home: (        )      -       Work: (         )          -        , ext.         Cell: (    )   -

Provide number where you can be reached on Uniform Notification Day? (Inform sites of any changes)

               Home   Work       Cell     Other: (          )        -       , ext.

Academic Training
Doctoral Program

Institution:                                                        City/State:

Major/Program/Subfield:                 Degree Sought:

Name of Training Director:

Is your program APA accredited?

Expected Date of Degree Completion:            /

Doctoral Requirements

CAPIC Uniform Application (CUA)                                                                       Page 2 of 4

        Date coursework completed, or expected to be complete:         /

        List coursework expected to remain incomplete as of the beginning of the training year (July 1st):


        Please indicate where you are in the dissertation process:

        When did you complete, or do you expect to complete your dissertation?         /

        What is your dissertation title or topic?

        Additional comments or description of study (optional):

Comprehensive Exams:

        I have completed my exam(s).

        I expect to complete my exams by            .

        I have not yet scheduled my exams.

Doctoral Candidacy:

        Have you advanced to candidacy?

Masters Degree (if applicable):

Institution:              City/State:

Major/Program:                  Year Degree Conferred:

College Degree

Institution:              City/State:

Major/Program:                  Year Degree Conferred:

Other Graduate Training

Institution:              City/State:

Major/Program:                  Units Completed:                Year Degree Conferred:

NOTE: Other academic training programs and degrees not entered here should be listed clearly on your CV.
CAPIC Uniform Application (CUA)                                                                             Page 3 of 4

Clinical Training

Summary of Clinical Experience
Number of intake interviews conducted: 0
Number of adult clients seen in short-term therapy (1-20 sessions): 0
Number of adult clients seen in long-term therapy (>20 sessions): 0
Number of child/adolescent clients seen in short-term therapy (1-20 sessions): 0
Number of child/adolescent clients seen in long-term therapy (>20 sessions): 0
Number of families seen in family therapy: 0
Number of couples seen in couples therapy: 0
Number of distinct psychotherapy groups facilitated: 0
Number of testing batteries* administered, scored and interpreted: 0
     *(A battery should include both objective and projective tests)
Number of assessment reports written: 0
Other experiences of note:

Please list all languages spoken other than English. Indicate your ability to work clinically in that language by
also describing your level of fluency:

Licenses, etc.
Please list any current and valid licenses, certificates, or registrations that allow you to practice in any field of
mental health, and the state in which it was issued.

Letters of Recommendation
Please provide the name, phone number and email address of all individuals writing letters of recommendation
in support of your application:
CAPIC Uniform Application (CUA)                                                                       Page 4 of 4

You are required to respond to two essays. Essay 1 is mandatory for all applicants. You may choose to respond
to either Essay 2.A or Essay 2.B. Each response must be 500 words or less.

1) In an autobiographical statement, please describe your relevant personal and professional development. You
   are free to go into as much detail as you feel is appropriate.

2) Please choose one of the following essays:

2.A) Please describe your theoretical orientation and how this influences your clinical work.

OR: 2.B) Please describe how your work in this setting, and with this specific population, will contribute to your
  development as a psychologist and enhance your experience and knowledge of multicultural/diversity issues.
  (Note that this is a site-specific essay, and it should be tailored to each site to which you are applying).

By signing below I attest that all information provided herein is true to the best of my knowledge and that I have
not intentionally misrepresented myself or doctoral program in any way. I understand that any intentional
falsification, on this application or during any aspect of the internship application process, may lead to a
withdrawal of consideration or dismissal from the internship program.

Furthermore, I agree to comply with all CAPIC policies, the APA Ethical Principles of Psychologists and Code
of Conduct, as well as with the Laws and Regulations of the California Board of Psychology. By signing below I
also agree to comply with the rules and policies of the internship program and institution(s) in which the
internship training takes place.

I have read fully the information provided to me regarding the internship program to which I am applying, and
agree to start the internship on the date specified in these materials.

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Applicant Signature                                          Date

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