APPLICATION FOR THE 
POSTDOCTORAL RESIDENCY IN
CLINICAL PSYCHOLOGY

The Institute of Living / Hartford Hospital

General Information	
Full Name	 	
Home Address		
E-mail Address		
Work Address		
Telephone Numbers	 (h);                    (w);                       (c): 	
APPCN Registrant Number*	 	

The following items are to be arranged and sent by the applicant.  Applications that are incomplete will not be reviewed.

1.	Curriculum vitae
2.	Three (3) professional letters of reference.  One letter should be provided from an internship supervisor.
3.	An official graduate transcript 
4.	Work samples:  For applicants to the neuropsychology and child/adolescent school-based areas of focus, 2 Neuropsychological or Psychological test reports (preferably from different supervisors), which must include a section addressing emotional/personality functioning.
5.	A complete postdoctoral application form.

Applicants are expected to have completed all doctoral degree requirements—including dissertation—prior to the start of the postdoctoral fellowship.

All application materials, including letters of reference, and/or questions are to be directed to:

The Institute of Living/Hartford Hospital
ATTN: Paula Snedeker, AAIII
Application for Postdoctoral Residency
200 Retreat Avenue
Hartford, CT. 06106

Phone:  (860) 545-7167
 Fax:      (860) 545-7222
E-mail: james.degiovanni@hhchealth.org  

*Neuropsychology applicants only
ACADEMIC EXPERIENCE

Doctoral Program	 	
Name:	 	
Address:	 	
Phone number:	 	
 	 	
Graduate Training Director:	 	
Name:	 	
Phone number:	 	
 	 	
Program degree:	Ph.D.       Psy.D.    Other? Please Specify:	
APA approved?	 Yes             No	
 	 	
Internship	 	
Name:	 	
Address:	 	
Phone number:	 	
 	 	
Internship Training Director:	 	
Name:	 	
Phone number:	 	
 	 	
Internship APA approved?	 Yes             No	
 	 	
Dissertation	 	
Title:	 	
Status:	 	

Undergraduate & Graduate colleges attended (if other than Doctoral Program:	
Name	Dates	Degree	

 	 	 	

 	 	 	

GRADUATE COURSEWORK

Please list all GRADUATE courses (including course titles and grades) as well as other relevant didactic experiences you have had in the following core areas.  It is anticipated that many of these areas may not have been formally covered in your graduate and/or internship training and, as such, will be incorporated as part of your postdoctoral training experience.  Sections III and IV are for Neuropsychology applicants only.  These specific learning areas form the core knowledge base outlined by the Houston Conference Guidelines for specialized education and training in clinical neuropsychology.  

AREA	COURSE TITLE	GRADE	
I.  General Psychology Core	
A. Statistics & Methodology			

B.  Learning, Cognition & Perception			

C.  Social Psychology & Personality			

D.  Biological Basis of Behavior			

E.  Life Span and Development			

F.  History and Systems			

G.  Cultural & Individual Differences & Diversity			

II.  Generic Clinical Core	
A.  Psychopathology			

B.  Psychometric Theory			

C.  Interview & Assessment Techniques (including personality & cognitive assessment)			

D.  Intervention techniques, including:

* Group Psychotherapy

* Family / Marital Psychotherapy

* Cognitive Behavioral Approaches

* Brief Therapy

* Other			

			

			

			

			
			
E.  Professional Ethics			

III.  Foundations for the Study of Brain-Behavior Relationships	
A.  Functional Neuroanatomy			

B.  Neurological & Related Disorders, including etiology, pathology, course & treatment			

C.  Non-Neurologic Conditions Affecting CNS Functioning			

D.  Neuroimaging & Other Neurodiagnostic Techniques			

E.  Neurochemistry of Behavior (e.g., psychopharmacology)			

F.  Neuropsychology of Behavior			

IV.  Foundations for the Practice of Clinical Neuropsychology	
A.  Specialized Neuropsychological Assessment Techniques			

B.  Specialized Neuropsychological Intervention Techniques			

C.  Research Design & Analysis in Neuropsychology			

D.  Professional Issues and Ethics in Neuropsychology			

E.  Practical Implications of Neuropsychological Conditions			

Please indicate the numbers of patients you have treated in PSYCHOTHERAPY according to the following diagnoses: (DO NOT INCLUDE PATIENTS SEEN AS PART OF TESTING).

DISORDER	INPATIENT	OUTPATIENT	
Mood Disorders			
Psychotic Disorders			
Anxiety Disorders			
Somatoform Disorders			
Dissociative Disorders			
Sexual Disorders, Paraphilias & Gender Identity Disorders			
Substance-Related Disorders			
Dementias			
Borderline Personality Disorder			
Other Personality Disorders (specify):
1.
2.
3.			

			
Child Disorders:
1.  Conduct Disorders
2.  Developmental Disorders
3.  Learning Disorders
4.  ADD/ADHD
5.  Other:			

			

			

Professional Statement
Please prepare and attach a professional statement that addresses the following:
•	Why did you chose the field of clinical psychology?
•	What Area of Emphasis are applying to and What are your postdoctoral residency training goals?
•	What is your clinical orientation and/or area of special interest in the field of clinical psychology?
•	What are your experiences to date with regard to psychotherapy.
•	What are your experiences to date with regard to assessment.
•	What are your research interests?
•	Discuss the strengths and limitations of the training that you have obtained up until this point in time.
•	What are your long-term career goals and plans for the future?

References
Please list the contact information for the individuals who will be providing your letters of references.  Note: One should be an internship supervisor.  These individuals should be familiar with your work.

Name:	 	
Title:	 	
Phone number:	 	
Address:	 	
 	 	
Name:	 	
Title:	 	
Phone number:	 	
Address:	 	
 	 	
Name:	 	
Title:	 	
Phone number:	 	
Address:	 	

Please indicate your familiarity with the following measures by checking the appropriate column.  It is not expected that you will have administered and/or knowledge of all of these measures at the time of your postdoctoral fellowship.  This is requested in order to obtain a sense of your overall testing experience.  Applicants to the positions in the Anxiety Disorders Center do not need to fill out these sections

Adult Tests
 	Independently
Administer	Familiar
With	No
Experience	
TOMM	 	 	 	
Word Memory Test	 	 	 	
VIP	 	 	 	
WAIS-III	 	 	 	
WAIS-IV	 	 	 	
Stanford-Binet	 	 	 	
TONI-III	 	 	 	
Reynolds Intellectual Assessment Scale	 	 	 	
Dementia Rating Scale-II	 	 	 	
RBANS	 	 	 	
Delis-Kaplan Executive Function System	 	 	 	
Wisconsin Card Sorting Test	 	 	 	
Category Test	 	 	 	
Stroop	 	 	 	
Trail Making Test	 	 	 	
Color Trails	 	 	 	
Behavioral Dyscontrol Scale	 	 	 	
WMS-III	 	 	 	
WMS-IV	 	 	 	
CVLT-II	 	 	 	
Hopkins Verbal Learning Test	 	 	 	
Rey Osterreith Complex Figure Test	 	 	 	
Boston Naming Test	 	 	 	
Controlled Oral Word Association Test	 	 	 	
Peabody Picture Vocabulary Test	 	 	 	
Boston Diagnostic Aphasia Exam	 	 	 	
Judgment of Line Orientation	 	 	 	
Hooper	 	 	 	
Sensory Perceptual Exam	 	 	 	
Finger Tapping	 	 	 	
Hand Dynamometer (grip strength)	 	 	 	
Grooved Pegboard	 	 	 	
Geriatric Depression Scale	 	 	 	
BDI-II	 	 	 	
BAI	 	 	 	
Personality Assessment Inventory (PAI)	 	 	 	
MMPI-II	 	 	 	
MCMI				
Rorschach	 	 	 	
Human Figure Drawings				
Other Projective Tests				
Thematic Apperception Test (TAT)	 	 	 	

Child and Adolescent Tests	 	 	 	
BASC				
Connors				
WISC-IV				
NEPSY-II	 	 	 	
Children's Memory Scale (CMS)	 	 	 	
WRAML-II	 	 	 	
CVLT-C	 	 	 	
WIAT-II	 	 	 	
Woodcock Johnson-Revised	 	 	 	
GORT-IV	 	 	 	
MAPI, MMPI-A				
Rorschach				
TAT, RATC				
Other Measures:	 	 	 	

	 	 	 	

	 	 	 	

 	 	 	 	

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