APPLICATION FOR ADMISSION IN DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY (CLINICAL PsyD)

Transcription

1 ALLIANT INTERNATIONAL UNIVERSITY California School of Professional Psychology (CSPP) APPLICATION FOR ADMISSION IN 2012 DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY (CLINICAL PsyD) A passport-sized photograph of the applicant should be attached to this form, with an additional photograph enclosed with the form when it is returned to the Registrations Office, California School of Professional Psychology (CSPP), Alliant International University (AIU) c/o School of Continuing and Professional Education (SCOPE), City University of Hong Kong, Tat Chee Avenue, Kowloon, Hong Kong. _ SECTION A Surname (block letters)...mr/mrs/miss/ms Other Names:... Home Address:... Please attach a passport-sized photograph here, and enclose an additional photograph with your application Hong Kong Identity Card / Passport Number:... Sex:... Permanent HK Resident O Yes O No Telephone Number: Work... Home... Mobile Fax:... Date of Birth:... Country of Birth:... Country of Citizenship:... Current Employment: Name and Address... Position and Starting Date of Appointment... Have you ever been convicted of a criminal offence (other than a traffic violation)? O Yes O No If yes, please attach a statement of explanation specifying the date of conviction, offence and disposition. Please note that a conviction will not necessarily disqualify an applicant from acceptance. (A felony record will not necessarily disqualify an applicant from acceptance, but may prevent or delay some forms of licensure.) How did you hear about Alliant? O Friend O Alumnus/are O Faculty O Internet Search O Newspaper Ad O Magazine Ad O Radio O TV O Alliant Mailing O Other

2 SECTION B SECTION B1 - ACADEMIC QUALIFICATIONS (Attach an extra page if necessary.) (Please also attach the most current Curriculum Vita with this application) Qualifications First Degree (include class/division and subject, if applicable) Award Obtained* Awarding Institution Date Awarded Period of Study GPA Higher Degree(s) State whether by coursework / dissertation / thesis or wholly by research Dissertation / Thesis Title(s) (if applicable) Initial Professional Qualification Advanced Professional Qualification Other Academic / Professional Awards Please attach evidence of your qualifications in the form of photocopies. Full transcripts including grades awarded should be sent to the designated address. Original documents should not be sent but please bring them with you for verification when you register. SECTION B2 - RELEVANT PROFESSIONAL EXPERIENCE RELEVANT PROFESSIONAL EXPERIENCE: (List in reverse chronological order) Position Held with Name of Institution and Job Duties Type of Institution Date from to

3 SECTION B3 - PREPARATION IN PSYCHOLOGY COURSES (Use additional pages if necessary and attach them to this form) Course Title Equivalent Course Title Institution Dept. and Course No. Term and Year Introduction Statistics Tests and Measurements OR Developmental Psychology OR Lifespan Development OR Human Growth and Development Abnormal Psychology OR Psychopathology Experimental Psychology OR Physiological Psychology OR Learning Theory OR Social Psychology SECTION B4 - RESEARCH TRAINING AND EXPERIENCE Please provide details, including type and place, of any training in specific research methods that you have had either as part of your academic studies or work.

4 SECTION C - RESEARCH & PRACTICES INTEREST I. What applied clinical problem would you most like to focus on in your PsyD studies and in the PsyD clinical dissertation project? II. What are your interests in practica/internship? SECTION D - REFEREES (Applications cannot be fully considered until references are received) I. List two persons who have agreed to act as referees with regard to your work/study. One should be able to comment on your academic work including your aptitude for research and scholarship. Another one should be able to comment on your professional competence and attitude. The referees should be non-blood relatives who are familiar with your work, your academic abilities, or your potential for scholarship and professional accomplishment. If you have been out of school for several years, please feel free to submit references from persons who are familiar with you on any level of professional involvement II. Please forward a copy of the enclosed reference form to the referee named and asks that it be completed and sent directly to the California School of Professional Psychology via the School of Continuing and Professional Education, City University of Hong Kong. DECLARATION I hereby certify the information given in this application is correct and complete to the best of my knowledge, and hereby give my permission to the Admissions Committee to obtain any verification deemed necessary to process my application. I further certify that I will arrange for the forwarding of official transcripts and other documents as requested in the application instructions. I will include with this application the non-refundable application fee. I understand that all submitted documents become the property of the University and will not be forwarded to another institution nor returned to me. ALL APPLICANTS PLEASE NOTE: Falsification of the application and/or supporting credentials will be grounds for immediate refusal of an application and/or dismissal from the University. Name of Applicant: Signature of Applicant: Date:

5 ALLIANT INTERNATIONAL UNIVERSITY REFERENCE FORM DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY (CLINICAL PsyD) Please return directly to Registrations Office HK PsyD Program CSPP at AIU c/o SCOPE City University of Hong Kong Tat Chee Avenue Kowloon, Hong Kong Each applicant is asked, after completing Section A below, to hand or send this sheet to the person who has agreed to act as referee concerning his/her work in Clinical Psychology/related fields. The reference should be sent directly to the University. This report will be handled as Confidential and be used for the purpose of assessing the applicant s admission suitability to the said program, and it will be accessible only to those responsible for processing the application. Two references are required for all applicants. It is your responsibility to see that the completed reference forms arrive by the application deadline. Give the people you ve chosen as referees the opportunity to begin working on them as soon as you make the decision to apply. The referees should be non-blood relatives who are familiar with your work, your academic abilities, or your potential for scholarship and professional accomplishment. If you have been out of school for several years, please feel free to submit recommendations from persons who are familiar with you on any level of professional involvement. SECTION A (to be completed by the applicant in Capital letters) Reference concerning (applicant's name, in Capital letters) who has applied to the California School of Professional Psychology of the Alliant International University for admission to a program leading to the award of Doctor of Psychology (Clinical PsyD). (Details may be obtained from the address above). Name of Referee: Dr/Mr/Ms.. Contact Phone No.: . SECTION B (To be completed by the Referee) The Referee named above is requested to answer all the questions below concerning this applicant, and then to send the form under confidential cover directly to the Registrations Office at the California School of Professional Psychology via the School of Continuing and Professional Education, City University of Hong Kong. The University would like to thank in advance for the kind assistance of the Referee to provide accurate and valuable opinions. 1. How long and in what capacity have you known the applicant? 2. Please list any unique/special qualities or skills, or any other qualifications that you think make this individual a viable candidate for the Clinical PsyD program. 3. What are the applicant s primary strengths and weaknesses? Please describe instances or accomplishments which demonstrate them. see over/...

6 4. Comment on the applicant s competency in his/her area of specialization (technical knowledge, analytical ability, attention to detail, and creativity) and his/her potential for achievement. 5. Please assess by a checkmark the applicant relative to other employees or students whom you have known in a similar capacity. Outstanding top 2% Superior top 10% Good top third Fair middle third Poor bottom third Unable to judge Intellectual ability Industry/motivation/initiative Emotional maturity Judgement Creativity/original/resourcefulness Ability to work with others Ability to organize Effectiveness in oral communication Effectiveness in written communication Academic preparation/knowledge of field Independence of thought Perseverance Sensitivity to diversity Empathy towards others 6. What is your overall recommendation? O Strongly recommend O Recommend O Recommend with some reservation (please explain) O Do not recommend (please explain) Name of Applicant Signature of Referee Name of Referee (Please Print) Position/Title Institution/Organization Business Address & Phone Number

7 ALLIANT INTERNATIONAL UNIVERSITY REFERENCE FORM DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY (CLINICAL PsyD) Please return directly to Registrations Office HK PsyD Program CSPP at AIU c/o SCOPE City University of Hong Kong Tat Chee Avenue Kowloon, Hong Kong Each applicant is asked, after completing Section A below, to hand or send this sheet to the person who has agreed to act as referee concerning his/her work in Clinical Psychology/related fields. The reference should be sent directly to the University. This report will be handled as Confidential and be used for the purpose of assessing the applicant s admission suitability to the said program, and it will be accessible only to those responsible for processing the application. Two references are required for all applicants. It is your responsibility to see that the completed reference forms arrive by the application deadline. Give the people you ve chosen as referees the opportunity to begin working on them as soon as you make the decision to apply. The referees should be non-blood relatives who are familiar with your work, your academic abilities, or your potential for scholarship and professional accomplishment. If you have been out of school for several years, please feel free to submit recommendations from persons who are familiar with you on any level of professional involvement. SECTION A (to be completed by the applicant in Capital letters) Reference concerning (applicant's name, in Capital letters) who has applied to the California School of Professional Psychology of the Alliant International University for admission to a program leading to the award of Doctor of Psychology (Clinical PsyD). (Details may be obtained from the address above). Name of Referee: Dr/Mr/Ms.. Address:. Contact Phone No.: . The Referee named above is requested to answer all the questions below concerning this applicant, and then to send the form under confidential cover directly to the Registrations Office at the California School of Professional Psychology via the School of Continuing and Professional Education, City University of Hong Kong. The University would like to thank in advance for the kind assistance of the Referee to provide accurate and valuable opinions. 1. How long and in what capacity have you known the applicant? 2. Please list any unique/special qualities or skills, or any other qualifications that you think make this individual a viable candidate for the Clinical PsyD program. 3. What are the applicant s primary strengths and weaknesses? Please describe instances or accomplishments which demonstrate them. see over/...

8 4. Comment on the applicant s competency in his/her area of specialization (technical knowledge, analytical ability, attention to detail, and creativity) and his/her potential for achievement. 5. Please assess by a checkmark the applicant relative to other employees or students whom you have known in a similar capacity. Outstanding top 2% Superior top 10% Good top third Fair middle third Poor bottom third Unable to judge Intellectual ability Industry/motivation/initiative Emotional maturity Judgement Creativity/original/resourcefulness Ability to work with others Ability to organize Effectiveness in oral communication Effectiveness in written communication Academic preparation/knowledge of field Independence of thought Perseverance Sensitivity to diversity Empathy towards others 6. What is your overall recommendation? O Strongly recommend O Recommend O Recommend with some reservation (please explain) O Do not recommend (please explain) Name of Applicant Signature of Referee Name of Referee (Please Print) Position/Title Institution/Organization Business Address & Phone Number

9 APPENDIX TOEFL (Test of English as a Foreign Language) TWE (Test of Written English) Applicant s Name Applicant International University s programs are very demanding and the school attempts to ensure that students have an adequate level of English proficiency to enter the program. Applicants whose native language is not English or who have not earned an undergraduate or graduate degree from a University using English as teaching medium are required to show English proficiency and must submit results of the Test of English as a Foreign Language (TOEFL) given by the Educational Testing Services (ETS) and the Test of Written English (TWE). Please complete one of the items below: O I have taken/plan to take the TOEFL on (date) and will have ETS forward a copy of the official test result directly to CSPP at AlU via SCOPE, CityU of Hong Kong. O I have taken/plan to take the TWE on (date) and will have ETS forward a copy of the official test result directly to CSPP at AlU via SCOPE, CityU of Hong Kong. Signature Date Signed O I am requesting exemption from the TOEFL requirement. Please list reasons below. O I am requesting exemption from the TWE requirement. Please list reasons below.