PSYDOC ANNUAL PROFESSIONAL PRACTICE UPDATE

ANNUAL PROFESSIONAL PRACTICE UPDATE - Published

Doctoral Program in Clinical Psychology
Name

First NameLast Name
Date

MonthDayYear
Date
Email*
example@example.com
If you are currently practicing as a mental health professional, complete Sections A through C. Do not include practica, clerkship, internships, or other experiences required as part of your training or education. Be advised that only those students who have obtained certification or licensure from a recognized professional agency and who have established a history of professional practice may be allowed to function in private professional capacity with departmental approval while enrolled in the Wheaton College Graduate School. Even under those circumstances the practice of such students will be closely monitored and limited by the department. The guidelines for such situations are contained in Section 1 of the Clinical Training Handbook.
A. Professional Practice

List the agencies in which you are currently practicing as a mental health professional. List also your role and the total hours per week providing mental health services (excluding supervision). Indicate any practice which is "private practice" as defined in the Clinical Training Handbook.

Rows	Setting	Role	Hours	Private? Y/N
1.
2.
3.

B. Supervision

For each of the settings, in the same order as listed above, detail the supervision you receive. List the qualifications of the supervisor (e.g., licensed psychologist, certified marriage and family therapist, etc.), the frequency of the supervision (e.g., weekly, monthly), the type of supervision (one-to-one or group; if the supervision is not face-to-face please specify), and the duration (number of hours, weekly or monthly).

Rows	Name & Qualifications	Address	Phone Number	Type	Frequency & Duration
1.
2.
3.

Professional Practice Credentials
C. Licensure / Certification
YesNo
If yes, list the state and the title on your license or certificate.

Also, please request that the appropriate board of your state send notification of your license / certification to the following address: School of Psychology, Counseling & Family Therapy, Wheaton College, 501 College Avenue, Wheaton, IL, 60187.
State: Title:
My signature below indicates that all of the information contained on this form is factually correct and honestly presented. I have read the guidelines for professional practice contained in the Clinical Training Handbook. I understand the policy and I am in compliance with it.
Signature & Date:*
Date

MonthDayYear
Date

I am the

DCT Approval
Signature
Date

MonthDayYear
Date
ApprovedRejected

Thank You For Completing This Form

Please submit the form using the button below.
Should be Empty:

ANNUAL PROFESSIONAL PRACTICE UPDATE - Published

Professional Practice Credentials

DCT Approval

Thank You For Completing This Form