ࡱ> 685` bjbjss .  dddddddx xG88888888$9hndr88rrdd88r d8d8rdd8, @A; |F0Gd$8Z@4l888 888Grrrrxxx xxx xxxdddddd UNIVERSITY OF CENTRAL ARKANSAS Department of Psychology & Counseling School Psychology Program Practicum / Internship Supervisor Information Form Student Supervisor Site Semester &Year Thank you for your time completing this form. It is used for programmatic purposes in order to ensure quality supervision for our students. Please return to the UCA School Psychology faculty. 1. Where did you attend graduate school? 2. In what area was your graduate program? School psych Clinical psych Counseling psych Other 3. Was your graduate program Accredited by the APA? Approved by the NASP? Other? 4. Where did you complete your internship? 5. Was the internship site accredited by the American Psychological Association? Yes No 6. In what setting(s) have you received supervision or been employed? Elem./Sec. School Clinic University Hospital Other 7. With which of the following age groups HAVE you worked? Children birth to 5 years School age children Adults 8. With which of the following groups HAVE you worked? Children with learning disabilities Children with emotional disorders Children with mental retardation Children with physical impairments Children with other educational disabilities Children with other DSM-IV diagnoses 9. With which of the following racial/ethnic groups HAVE you worked? Caucasians Blacks Latino/Latina Asian American / Pacific Islander Native American 10. With which of the following age groups ARE you working currently? Children birth to 5 years School age children Adults 11. With which of the following groups ARE you working currently? Children with learning disabilities Children with emotional disorders Children with mental retardation Children with physical impairments Children with other educational disabilities Children with other DSM-IV diagnoses 12. With which of the following racial/ethnic groups ARE you working currently? Caucasians Blacks Latino/Latina Asian American / Pacific Islander Native American 13. Check any of the following activities that are included in your current professional role? Psycho-educational assessment Consultation Psychological assessment Crisis Intervention Neuropsychological assessment Program development Individual/group therapy Program evaluation Family therapy Preventative intervention Work with unique population Early intervention Behavior Plans / FBA Other 14. Which of the following credentials do you currently hold? Licensed School Psychology Specialist - AR Department of Education Licensed Psychological Examiner - AR Board of Examiners in Psychology Licensed Psychologist - AR Psychology Board Nationally Certified School Psychologist - NASP Other Revised by JBS 8/30/07 abz     , - 4 ; = [ ] ^ v w % ' ( . / 4 z | }     3 4 u v 9 : h3=5\ h3=>*hqDh3=5]hqDhq5]h3=hqDh3=\Sab + < = [ % 3 4 z $a$$a$ < = t  8 ` b Nc 6$a$: OPkl>?de&'78[\/0OPfg ^_` RSZeihqDhqDCJaJ h3=5\ h3=PJ h3=>*PJ h3=>*h3=R6mn.e ^Qfghi ]^]^` 0^`0$a$,1h/ =!"#$% @@@ NormalCJ_HaJmH sH tH >@> Heading 1$$@&a$>*DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List <B@< Body Text  6]>P@> Body Text 2$a$5\  ab+<=[%34z<=t8`bNc 6mn. e  ^  Q f g h i 0000000000000000000000000000000000000000000000000000000000000000000000000000:   6  tnItnԟItn