PSYDOC Clinical Dissertation Committee Application

Name

First NameLast Name

Student ID

Your email:

example@example.com

Date

The purpose of this form is to document your clinical dissertation committee.

Committee composition: Each committee is comprised of three (3) members; a Chair and two readers. The composition of your committee must include a Chair who is a member of the Wheaton College Psychology Department and one core Psy.D. faculty member. Two of three members mustbe members of the Wheaton College Psychology Department, and the third may be from outside the department as long as they hold an earned doctorate in psychology or a related discipline and have been approved by the committee Chair.

Readers from outside the department: Readers from outside the department are paid a stipend at the end of the year of clinical dissertation proposal defense. Their address must be completed in order for your reader to receive a stipend. If you have an outside reader, please list them as Reader #2. They will be prompted to provide their address.

Advisor change: In the event that the committee Chairperson is not a core Psy.D. faculty member, then a core Psy.D. reader will be named as the student’s advisor.

Chair

First NameLast Name

Core PsyD Faculty?

YesNo

Chair Email

example@example.com

Reader #1

First NameLast Name

Core PsyD Faculty?

YesNo

Reader #1 Email

example@example.com

Reader #2

First NameLast Name

Core PsyD Faculty?

YesNo

Reader #2 Email

example@example.com

Additional comments

Chair Signature:

Reader #1 Signature:

I am a Wheaton College Employee

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number

Reader #2 Signature:

I am a Wheaton College Employee

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number

Clinical Dissertation Committee Application - Published