ࡱ> @ ~Wbjbjצצ (z0$$$$$$$88T |8 7l(!#M6O6O6O6O6O6O6$v8R:s6Q$='='='s6$$6G0G0G0='$$M6G0='M6G0G0:b3o$$ 4 ˒)3 460 73.H;*H; 488$$$$H;$ 4$Z %@G0`%4%$$$s6s688/X88Northwestern University Counseling and Psychological Services POST-DOCTORAL FELLOW APPLICATION FORM 1. Name:  FORMTEXT       Date:  FORMTEXT        2. Address:  FORMTEXT        FORMTEXT        FORMTEXT       E-mail address:  FORMTEXT        3. Home Phone:  FORMTEXT      Work Phone:  FORMTEXT       4. Doctoral Program: Name of School:  FORMTEXT       Graduation Date:  FORMTEXT       Dissertation Title:  FORMTEXT       Degree:  FORMCHECKBOX PhD  FORMCHECKBOX PsyD  FORMCHECKBOX EdD Type of Program:  FORMCHECKBOX  Counseling Psychology  FORMCHECKBOX  Clinical Psychology  FORMCHECKBOX  Other (Specify:  FORMTEXT      ) APA Accredited?  FORMCHECKBOX  Full  FORMCHECKBOX  Provisional  FORMCHECKBOX  Probationary  FORMCHECKBOX  Not Accredited Program Address:  FORMTEXT        FORMTEXT        FORMTEXT       Program Director:  FORMTEXT       Phone #:  FORMTEXT       GPA:  FORMTEXT        5. Internship Site: APA Accredited?  FORMCHECKBOX  Full  FORMCHECKBOX  Provisional  FORMCHECKBOX  Probationary  FORMCHECKBOX  Not Accredited Name of Training Director:  FORMTEXT       Names of Supervisors:  FORMTEXT        FORMTEXT        PLEASE BRIEFLY DESCRIBE: Your experience in providing clinical supervision to others?  FORMTEXT       Type of Supervision of supervision provided to you:  FORMTEXT       Types of outreach programs you have developed and/or provided:  FORMTEXT        FORMTEXT        FORMTEXT       Types of groups you have led or co-led:  FORMTEXT       Crisis & case management experiences:  FORMTEXT       Other specialized training or experiences:  FORMTEXT       6. Please indicate your best estimate for each item below: Number of intake interviews conducted:  FORMCHECKBOX  1-10  FORMCHECKBOX  11-20  FORMCHECKBOX  21-30  FORMCHECKBOX0|~ ( 4 6 J L N X Z \ ` b ǰkǰQk2jvhkhsA5CJOJQJU^JaJ1jhg5CJOJQJU^JaJmHnHu2jhkhsA5CJOJQJU^JaJ#hkhsA5CJOJQJ^JaJ,jhkhsA5CJOJQJU^JaJhsACJOJQJ^JaJhsAh^h]g h]gCJh]gCJOJQJ h]g5CJh]g@xCJ0|~( \ ^ ` %%%%v:%v:l v:\zkd$$Ifl0 d&zD t0644 la $IfgdsA$Ifgd]g$a$gd]ggd]ggd]g W|W` d  R T V b %s%s%v:gkd $$Ifld&& t0644 la$If $Ifgdk b d ͻ͈ͻn͈_N7,jhxhx>*CJOJQJU^JaJ hxhxCJOJQJ^JaJhk>*CJOJQJ^JaJ2jhy,hk>*CJOJQJU^JaJ1jhg>*CJOJQJU^JaJmHnHu2jNhy,hk>*CJOJQJU^JaJ#hy,hk>*CJOJQJ^JaJ,jhy,hk>*CJOJQJU^JaJh$CJOJQJ^JaJhkCJOJQJ^JaJ    * , @ B D N P R T V ` b Ӽ~lR~~D6/ hsAh[thFCJOJQJ^JaJhxCJOJQJ^JaJ2jhy,hk>*CJOJQJU^JaJ#hy,hk>*CJOJQJ^JaJ,jhy,hk>*CJOJQJU^JaJhkCJOJQJ^JaJ1jhg>*CJOJQJU^JaJmHnHu,jhxhx>*CJOJQJU^JaJ2j6hxhx>*CJOJQJU^JaJ#hxhx>*CJOJQJ^JaJb    > @ ̴ݜ̄ݜvdV?,jhd1lhk>*CJOJQJU^JaJhkCJOJQJ^JaJ#hkhk5CJOJQJ^JaJh[tCJOJQJ^JaJ/jhkhkCJOJQJU^JaJ.jhgCJOJQJU^JaJmHnHu/jihkhkCJOJQJU^JaJ hkhkCJOJQJ^JaJ)jhkhkCJOJQJU^JaJhkCJOJQJ^JaJ   f h  %sy%sy%shh%shh%shh%shh%s$If^`gdk $$Ifa$gdkxkdQ$$Ifl0d&hh t0644 la @ T V X b d    < Ӽ{aO#jhkCJOJQJU^JaJ2jhd1lhk>*CJOJQJU^JaJ2jhd1lhk>*CJOJQJU^JaJhkCJOJQJ^JaJ1jhg>*CJOJQJU^JaJmHnHu,jhd1lhk>*CJOJQJU^JaJ2jhd1lhk>*CJOJQJU^JaJ#hd1lhk>*CJOJQJ^JaJ< > @ H J f h j t v " > @ B v x ǯǗgO/j?hghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/jWhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/johghj&CJOJQJU^JaJhkCJOJQJ^JaJ#jhkCJOJQJU^JaJ/jhghj&CJOJQJU^JaJ  l Jz2%s%s%s $IfgdkK$$If^`gdk  (*,:<XZ\xz"սկկկկկկgկկOկ/j hghj&CJOJQJU^JaJ/j hghj&CJOJQJU^JaJ/j hghj&CJOJQJU^JaJ/j) hghj&CJOJQJU^JaJhkCJOJQJ^JaJ.jhgCJOJQJU^JaJmHnHu#jhkCJOJQJU^JaJ/jh[thkCJOJQJU^JaJ"$8:<FHRThjlvxz׽|זbזThkCJOJQJ^JaJ2j hd1lhk>*CJOJQJU^JaJ2jq hd1lhk>*CJOJQJU^JaJhkCJOJQJ^JaJ1jhg>*CJOJQJU^JaJmHnHu2j hd1lhk>*CJOJQJU^JaJ#hd1lhk>*CJOJQJ^JaJ,jhd1lhk>*CJOJQJU^JaJ   "$.06DFZ׽|nWE#hd1lhk>*CJOJQJ^JaJ,jhd1lhk>*CJOJQJU^JaJhkCJOJQJ^JaJ2j hd1lhk>*CJOJQJU^JaJhkCJOJQJ^JaJ1jhg>*CJOJQJU^JaJmHnHu2j] hd1lhk>*CJOJQJU^JaJ#hd1lhk>*CJOJQJ^JaJ,jhd1lhk>*CJOJQJU^JaJ246lnr%srl%s$If$If^`gdk|kdI $IfK$L$l0%4 t0644 laZ\^hjt24P϶Ϩv^vvFvv/jhghj&CJOJQJU^JaJ/jxhghj&CJOJQJU^JaJ#jhkCJOJQJU^JaJhkCJOJQJ^JaJ#hkhk5CJOJQJ^JaJhkCJOJQJ^JaJ1jhg>*CJOJQJU^JaJmHnHu,jhd1lhk>*CJOJQJU^JaJ2j hd1lhk>*CJOJQJU^JaJnprp%s%s%s~~%s~~%s~~x%s$If$If^`gdk $Ifgdkekd4$$Ifld&& t0644 la PRTrtHJ^`blnzǯǘlSǘ9S2jhd1lhk>*CJOJQJU^JaJ1jhg>*CJOJQJU^JaJmHnHu2jJhd1lhk>*CJOJQJU^JaJ#hd1lhk>*CJOJQJ^JaJ,jhd1lhk>*CJOJQJU^JaJ/jhghj&CJOJQJU^JaJhkCJOJQJ^JaJ#jhkCJOJQJU^JaJ/j`hghj&CJOJQJU^JaJz|XZnpr׽זzhV>V/jh|h)zJCJOJQJU^JaJ#jh|CJOJQJU^JaJ#h|h|5CJOJQJ^JaJhg;SCJOJQJ^JaJh|CJOJQJ^JaJhkCJOJQJ^JaJ1jhg>*CJOJQJU^JaJmHnHu2j6hd1lhk>*CJOJQJU^JaJ#hd1lhk>*CJOJQJ^JaJ,jhd1lhk>*CJOJQJU^JaJX%s%s{{%s%s%s%s%s v^v`gd| ^`gd|gd`ekd$$Ifld&& t0644 lar|~ȶȞȶw_/jRh|h)zJCJOJQJU^JaJ/jh|h)zJCJOJQJU^JaJhg;S5CJOJQJ^JaJ/jfh|h)zJCJOJQJU^JaJ#h)zJh|5CJOJQJ^JaJh|CJOJQJ^JaJ#jh|CJOJQJU^JaJ.jhgCJOJQJU^JaJmHnHu dfh|~Z`bvxzսկկսկկmսկկUսկ/j*h|h)zJCJOJQJU^JaJ/jh|h)zJCJOJQJU^JaJ/j>h|h)zJCJOJQJU^JaJ#h)zJh|5CJOJQJ^JaJh|CJOJQJ^JaJ.jhgCJOJQJU^JaJmHnHu#jh|CJOJQJU^JaJ/jh|h)zJCJOJQJU^JaJ!d^THHHII,J>K@KKLLLXMZM^M%s%s%s%s%s%s%s%s%s%s%s%s%s%s%s%s%s%s%s%s ^`gd|VXtvxHHHHHHHHHHHH~f/jxhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJU/jhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ#jh|CJOJQJU^JaJh|CJOJQJ^JaJ  31+ Number of clients seen in brief therapy (less than 15 sessions):  FORMCHECKBOX  0  FORMCHECKBOX  1-5  FORMCHECKBOX  6-10  FORMCHECKBOX  11-15  FORMCHECKBOX  16-20  FORMCHECKBOX  20+ Number of therapy groups (not sessions) facilitated or co-led:  FORMCHECKBOX  0  FORMCHECKBOX  1-3  FORMCHECKBOX  4-7  FORMCHECKBOX  8-10  FORMCHECKBOX  11-15  FORMCHECKBOX  16+ Number of outreach presentation / workshops conducted:  FORMCHECKBOX  0  FORMCHECKBOX  1-3  FORMCHECKBOX  4-7  FORMCHECKBOX  8-10  FORMCHECKBOX  11-15  FORMCHECKBOX  16+ 7. Please list, from most recent to most distant, your practicum hours: Name of PlacementType of ClientelePrimary Supervisor(s)Hours FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       In addition to this application form, the following materials should also be sent: Cover letter/statement of purpose indicating your interest in the program, its relationship to your professional goals, research or scholarly interests you would like to pursue, and the expected date of completion of the doctoral degree Curriculum Vita Transcripts of all graduate work Three letters of recommendation, at least one of which should come from your primary internship supervisor   FORMTEXT Send all materials to: John Dunkle, Ph.D. Director of CAPS Northwestern University 633 Emerson Street Evanston, IL 60208-4000 FAX: (847) 467-1193 Phone: (847) 491-2151 Or, e-mail to Christine Cox, Administrative Assistant at:  HYPERLINK "mailto:c-cox@northwestern.edu" c-cox@northwestern.edu  FORMTEXT END     Page  PAGE 1 of  NUMPAGES 3 HHHHHIIII II@INIPIlInIpI~IIIIIII.J0JLJǯǗgU#hg;Sh|>*CJOJQJ^JaJ/jhghj&CJOJQJU^JaJ/jPhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/jdhghj&CJOJQJU^JaJh|CJOJQJ^JaJ#jh|CJOJQJU^JaJ/jhghj&CJOJQJU^JaJLJNJPJXJZJvJxJzJJJJJJJJJJJJJKKKKK0K2K4KKKKǯǗgO/jhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/j(hghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJh|CJOJQJ^JaJ#jh|CJOJQJU^JaJ/j<hghj&CJOJQJU^JaJKKKKKKKK L L(L*L,L8L:LVLXLZLfLhLLLLLLLLLLǯǗgO/jNhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/jbhghj&CJOJQJU^JaJ/jhghj&CJOJQJU^JaJ/jvhghj&CJOJQJU^JaJh|CJOJQJ^JaJ#jh|CJOJQJU^JaJ/jhghj&CJOJQJU^JaJLLLLLVM\M^MMMMMMMNNN NN N"N,N.N0N2NFNHNJN䰣{nZ{F'j2!hd1lh)zJOJQJU^J'j hd1lh)zJOJQJU^Jhd1lh`OJQJ^J&jhgOJQJU^JmHnHu'jF hd1lh)zJOJQJU^Jhd1lh)zJOJQJ^J!jhd1lh)zJOJQJU^J h[th)zJCJOJQJ^JaJ#h)zJh)zJ5CJOJQJ^JaJh)zJCJOJQJ^JaJh[tCJOJQJ^JaJ^MMMMMMN0NXNNZ sZ s s4sUkd$$Ifl\@ rX d&2 2    t0644 laz $Ifgd| JNTNVNXNZNnNpNrN|N~NNNNNNNNNNNNNNNNNNNNNNNNNOOOκάΘ΄p\'j$hd1lh)zJOJQJU^J'j#hd1lh)zJOJQJU^J'j#hd1lh)zJOJQJU^J'j"hd1lh)zJOJQJU^Jh)zJCJOJQJ^JaJ'j!hd1lh)zJOJQJU^Jhd1lh)zJOJQJ^J!jhd1lh)zJOJQJU^J&jhgOJQJU^JmHnHu$NNNNN"O\SSSS $Ifgd|kd"$$IflC\@ rX d&2 2    t0644 lazOO O"O$O&O:OOHOJOLONObOdOfOpOrOtOvOOOOOOOOOOOOOOOOOOάΘ΄p\'j`'hd1lh)zJOJQJU^J'jd&hd1lh)zJOJQJU^J'j%hd1lh)zJOJQJU^J'jx%hd1lh)zJOJQJU^J'j%hd1lh)zJOJQJU^Jh)zJCJOJQJ^JaJhd1lh)zJOJQJ^J!jhd1lh)zJOJQJU^J&jhgOJQJU^JmHnHu$"O$OLOtOOO\SSSS $Ifgd|kd|$$$IflU\@ rX d&2 2    t0644 lazOOOP>PfP\SSSS $Ifgd|kd&$$Ifl \@ rX d&2 2    t0644 lazOOOOOOPPPPPPP,P.P0P:PP@PTPVPXPbPdPfPjPrPtPQQ͹ͥ͑̓ugWgh`h!35CJOJQJ^Jh!3CJOJQJ^JaJh`CJOJQJ^JaJh)zJCJOJQJ^JaJ'j(hd1lh)zJOJQJU^J'jL(hd1lh)zJOJQJU^J'j'hd1lh)zJOJQJU^Jhd1lh)zJOJQJ^J&jhgOJQJU^JmHnHu!jhd1lh)zJOJQJU^JfPhPjPlPnPpPtPQ\O%sO%sO%sO%s><'s><'$If^`gd!3 ^`gd|kd8)$$Ifl\@ rX d&2 2    t0644 lazQQRSXS0T2T4T6TTT<'s<'-<'<'<'7<'sna%sa\%gd? 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