Alaska Pacific University Previous Clinical Experience Form Please complete this form related to your previous clinical experience Previous experience includes employment, clinical volunteering, practica, and internships Name Email Address Address Nearest Metropolitan Area Have you had prior clinical experience? (Highlight the correct cell) Yes Inclusive dates for all formal graduate education TO No Total years of clinically relevant employment Direct Service Please indicate which modalities you have used (Mark appropriate items with an X) Individual Couple Group Family Estimated number of hours of direct, face-toface intervention with clients Estimated number of hours spent in direct, face-to-face psychological assessment Tests administered under supervision (Mark appropriate items) Mental Status Exam Rorschach Behavioral Observation TAT/CAT/SAT WAIS/WISC/WPPSI/WJ-COG Projective Drawings Bender/V-M Tests Neuropsycholgical Tests Symptom Inventories (e.g., MMPI-2/MMPI-A/MMPI-2RF BDI, SCL-90) MCMI/MAPI Other (please include) Supervision experience: Estimated # of hours of one-to-one, face-toface supervision with a licensed psychologist received: Estimated number of hours of face-to-face group/peer supervision received: Estimated # of hours of one-to-one, face-toface supervision with other licensed professional (e.g., LCSW, LPC, LPA, MD) received: Alaska Pacific University Previous Clinical Experience Form Estimated number of hours of supervision provided to others: Number of previous supervisees: Consultation experience: Estimated number of hours of clinical consultation provided to others: Estimated number of hours of research consultation provided to others: Program development/evaluation: Estimated number of hours of program development/evaluation: Prior Training Sites/Supervisors (please attach additional documentation if needed) Site Name and Address: Site Name and Address: Site Name and Address: Licenses currently held and in what state(s) Please attach a copy of all current licenses to your application Type of License, Number, and State: Type of License, Number, and State: Have you had any previous complaints or disciplinary actions filed against you? If yes, please explain (attach additional documentation if needed) Current employment (if clinical in nature): Site Name and Address: Any clinical relevant volunteer activities: Yes No Alaska Pacific University Previous Clinical Experience Form Site Name and Address: Please list any possible practicum training sites (within reasonable commuting distance) you are aware of: Site Name and Address: Site Name and Address: Site Name and Address: Site Name and Address: Alaska Pacific University Previous Clinical Experience Form