APPLICATION FORM FOR SCRUTINY UNDER DIRECTIVE 2005/36/EC

OF PROFESSIONAL QUALIFICATIONS IN CLINICAL PSYCHOLOGY

PLEASE READ INFORMATION NOTE AND GUIDE CAREFULLY BEFORE COMPLETING THIS FORM

PLEASE TYPE AND SIGN THIS FORM(hand written forms will not be accepted)

A. PERSONAL DETAILS

Surname: ___________________________________ Title: ___________________

Previous surname, if any: ______________________________________________

First name(s): ________________________________________________________

Date of birth: Day__ __ Month__ __ Year__ __ __ __

Address for correspondence: _______________________________________________________________________________________________________________________________________________________________________________________________________________

Email address: _______________________________________________________

Contact telephone number: ___________________________________________

Citizenship: __________________________________________________________(please submit a witnessed copy photographic ID)

Residency: if you are neither Swiss nor an EEA national1, are you legally resident in Ireland?

YES □ NO □

(If yes, please submit a witnessed copy of:(a) your certificate of registration issued by the Garda National Immigration Bureau and showing the

immigration stamp; and (b) passport endorsement.(The period of permission shown in the certificate and the passport should match.))

1 EEA (European Economic Area) comprises Member States of the European Union, Iceland, Liechtenstein and Norway.

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Eligibility to practise in the country in which qualification was obtainedAre you eligible to practise as a psychologist in the country in which qualification was obtained? YES □ NO □See also Section I

Contact details (name, address, telephone number, email) of the national competent authority which should verify that your qualification meets the standard to practise in the country in which qualification was obtained2

(Please submit a witnessed copy of evidence of the qualification giving access to the profession, translated into English if necessary)

Membership of professional bodyIf you are a member of any psychological societies please give details in the table below:

Name of Society Contact addressMembership

numberMembership

status

Statutory Registration

Does statutory registration exist in your country?

If yes are you statutorily registered?(if yes please submit a witnessed copy of your registration document)

Please give contact details of registration body (name, address, telephone number, email)

YES □ NO □

YES □ NO □Registration number:Period of registration:Scope of practice:

2 If you are an EEA national, please refer if necessary to the contact point for Directive 2005/36/EC in your home Member State.

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B. QUALIFICATIONS IN PSYCHOLOGY

Please list all your degrees and qualifications in psychology in chronological order, starting with the first.

Full title of the course as named by the degree awarding authority

Degree and grade obtained

Start date,completion date,

date awarded(month & year)

Type of study and assessment method

Name of university, institute, college or other

degree awarding authority Name of accrediting body

Undergraduate

Undergraduate

Postgraduate

Postgraduate

Notes about the row headings.Full title of the course: Please give the full title of your degree exactly as shown on the degree certificate, including such descriptions as Joint Honours or Combined Studies.

Degree and grade obtained: Please give the abbreviated title of your degree with your honours classification, for example, BA 2(1) Hons, MPsychSc, PhD

Type of study and assessment method: Full time/part time/distance learning, Show whether

your degree involved course work, empirical research, or some combination, and how it was assessed for example:

Course work and examination60% course and exam, 40% thesisResearch and thesisCourse work and continuous assessment

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C. UNDERGRADUATE QUALIFICATION IN PSYCHOLOGY

Indicate below how you see your education/training in psychology as meeting the requirements in relation to some or all of the following components. The components are in accord with the Psychological Society of Ireland (PsSI) Guidelines on the Accreditation of Courses Leading to a First Qualification in Psychology.

a. include only courses in psychology (generally courses presented in psychology departments or by suitably qualified psychologists);

b. indicate clearly which courses were taken at an advanced level; and c. include cross-references to the supporting documentation you have submitted,

e.g. the course code from your official transcripts

Component Information from applicantTranscript course reference number

Biological Bases of Behaviour

Required componentInclude areas such as: Neuropsychology, Physiological Psychology, Behaviour Analysis, and Animal Behaviour

Developmental Psychology

Required componentInclude areas such as: Child Psychology, Adolescence, Adulthood & Ageing, and Lifespan Development.

Cognitive Psychology

Required ComponentInclude areas such as:Perception, Memory, Thinking and Artificial Intelligence

Social Psychology

Required ComponentInclude areas such as:Group Behaviour, and Organisational Psychology

C. UNDERGRADUATE QUALIFICATION IN PSYCHOLOGY continued

Component Information from applicantTranscript course reference number

Personality and Individual Differences

Required componentInclude areas such as:Personality Theory, and psychoanalysis.

Research Methods

Essential componentInclude areas such as: Research Design, Psychological Statistics, Qualitative Methods, and Survey Methods.

Research ProjectSpecify any independent research and name of supervisor

Applied Psychology

Include areas such as: Psychology of Disability and Rehabilitation, Educational, Clinical, Health, Industrial, and Forensic Psychology

Other Areas of Psychology

Include areas such as: History of Psychology, Environmental, Cross-cultural Psychology, Theories of Psychology, and Professional Ethics

Communication and Interpersonal Skills

Include areas such as: Interviewing Techniques, Social Skills Training, Small Group Processes.

D. POSTGRADUATE QUALIFICATION IN CLINICAL PSYCHOLOGY

Full title of postgraduate training course:__________________________ From: _____________ to:______________ (insert month and year)

Year 1 _____weeks Year 2_____weeks Year 3_____weeks Year 4______weeks Year 5_____weeks.Proportion of total course time allocated to clinical placement experience_______%; to academic teaching_______%

Please give details of supervised placements during your professional training course

Placement setting(full name and address of

each placement) Age rangesDates

from/to

Total Number of placement

daysFrequency of supervision

Name & position of supervisor

Method of assessment

1. Adult Mental Health

2. Child and Adolescent Mental Health

3. Intellectual Disability

4. Specialist Placement

5.

6.

1. PLACEMENTS DURING TRAINING

Please provide details, for each placement outlined on previous page(s), of supervised training experience and skill development in the areas of a) assessment, b) formulation, c) written & oral communication, d) therapeutic models used, e) indirect work, f) multi-disciplinary contact, g) intervention and h) evaluation.

Adult Mental Health

Child and Adolescent Mental Health

Intellectual Disability

Specialist Placement

2. RANGE OF PRESENTING PROBLEMS

Please describe the range of presenting problems encountered in each placement.Placement type Presenting problems

Adult Mental Health

Child and Adolescent Mental Health

Intellectual Disability

Specialist Placement

3. THERAPEUTIC MODELS

What were the dominant therapeutic models taught and practised on your course?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. ACADEMIC PROGRAMME

Please describe the main topic areas covered including client groups; presenting problems, assessment, formulation, intervention, research methods & statistics, service based issues, professional/ethical issues and social/cultural issues. Cross reference by giving the course number or code from your official transcripts.

Year 1

Year 2

Year 3

5. ACADEMIC ASSESSMENT

Please give details of the academic work you submitted during training (indicate whether each piece was a case study, essay, research project, presentation or written/oral exam, thesis).

Title of work Description and approximate word count

6. THESIS

Applicant should supply the a) official abstract and b) a structured summary of the thesis of 250 to 400 words in length using the guidelines below.

Please provide:

The thesis title, number of words, and date examined Names of examiners and degree for which the thesis was presented Objectives: State the objective of the research and the main hypotheses or questions

addressed. Design: Describe the design specifying the number of groups studied, and the number of

occasions on which data were collected from these groups. Methods: State if quantitative or qualitative methods were used. Specify the number and

characteristics of participants; the assessment instruments, psychological tests or special apparatus used; and the procedures followed during data collection. 

Results: Give the main results. Numerical data may be given briefly. Data analysis: State the way qualitative data were processed or the statistics used to

analyse quantitative data. Conclusions: State the conclusions from the research and the implications of these for

clinical practice, policy development and further research. 

7. EXPERIENCE OF TEACHING/TRAINING/GIVING PRESENTATIONS DURING TRAINING

Topic Audience Date

E. SUPERVISED CLINICAL PSYCHOLOGY EXPERIENCE

It is recognised that training structures differ across countries. Work experience supervised by a clinical psychologist, gained after formal postgraduate training may be considered in meeting the requirements in regard to clinical placements.

Please give details of the work experience you have obtained under the supervision of a clinical psychologist. (If the spaces provided are insufficient please photocopy this page to accommodate additional information and attach the photocopied page to your application.)

Work experience(name and address)

Client groupand age ranges

Dates from/to

Number of days

Frequency of supervision

Name and position of supervisor

Method of assessment

1.

2.

3.

4.

1. PRESENTING PROBLEMS

Please describe the range of presenting problems encountered in each area of supervised work experience post qualification.

Supervised Work Experience Presenting Problems/Age ranges1.

2.

3.

4.

2. THERAPEUTIC MODELS

What were the dominant therapeutic models taught and practised during your supervised clinical experience?_______________________________________________________________________________________________________________________________________________________________________________________________________________

3. EXPERIENCE OF TEACHING/TRAINING/GIVING PRESENTATIONS DURING SUPERVISED CLINICAL EXPERIENCE

Topic Audience Date

F. EMPLOYMENT AS A PSYCHOLOGIST(If shortfalls in your academic qualifications are identified, post-qualification professional experience of the applicant must be considered so it is important that you provide

complete information on your post qualification work experience as a practising psychologist)

Job titleService name/client

group AddressDates

from/to

Hours per

week Main duties

Note: Job title (or occupation): Indicate with a bracket or in some other way any appointments you have held (or hold) concurrently.Dates from/to: Give month and year. It will be assumed that you are not working as a psychologist during any period not accounted for in your employment record.(If the spaces provided are insufficient please photocopy this page to accommodate additional information and attach the photocopied page to your application.)

G. ADDITIONAL INFORMATION

State here any other information you feel is needed to support your application.

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H. REFEREES

The Minister for Health is the Competent Authority for the assessment of psychology qualifications and is advised by Psychological Society of Ireland (PsSI). Either body may seek verification of the information provided by the applicant in relation to either professional training or subsequent professional experience.

You should identify two (2) referees – one for each area and ask that they each complete (in typed script) and sign the form overleaf. Appropriate referees would include the course co-ordinator or supervisor(s) during your professional training or senior psychologist(s) from your current or most recent employment.

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FOR COMPLETION BY REFEREE 1

THE DoH/PsSI RESERVES THE RIGHT TO CONTACT REFEREES DIRECTLY

The applicant is applying for recognition of professional qualifications in clinical psychology obtained outside of Ireland (Republic of Ireland) in order to work as a clinical psychologist in the health service in the Republic of Ireland.

The Department of Health and/or the PsSI may seek verification from you of the information provided by the applicant in relation to either professional training or subsequent professional experience.

Please complete in typed script and then sign and stamp.

1. Name: _______________________________________________________

2. Official job title/position:_______________________________________

3. Work address: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Email address: _____________________________________

5. Telephone number: _________________________________

6. Nature of contact during training/work experience/employment: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Referees should indicate their status within the psychological society of their own country:

Name of psychological society: ________________________________________

Status: ______________________________________________________________

Signed: _________________________________ Date: _____________________

Stamp of institution/service

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FOR COMPLETION BY REFEREE 2

THE DoH/PsSI RESERVES THE RIGHT TO CONTACT REFEREES DIRECTLY

The applicant is applying for recognition of professional qualifications in clinical psychology obtained outside of Ireland (Republic of Ireland) in order to work as a clinical psychologist in the health service in the Republic of Ireland.

The Department of Health and/or the PsSI may seek verification from you of the information provided by the applicant in relation to either professional training or subsequent professional experience.

Please complete in typed script and then sign and stamp.

1. Name: _______________________________________________________

2. Official job title/position:_______________________________________

3. Work address: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Email address: _____________________________________

5. Telephone number: _________________________________

6. Nature of contact during training/work experience/employment: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Referees should indicate their status within the psychological society of their own country:

Name of Psychological Society: ________________________________________

Status: ______________________________________________________________

Signed: _________________________________ Date: _____________________

Stamp of institution/service

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I. EVIDENCE OF QUALIFICATION

Please list below the evidence you have enclosed which shows that your qualifications entitle you to practice as a psychologist in the country in which your qualification was obtained. If your registration or licence specifies an area of practice, for example, Clinical Psychology, please include this.

1.

2.

3.

Please label each supporting document clearly

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J. DECLARATION

Any recognition granted on the basis of fraudulent or falsified information, material misrepresentation or misstatement designed to mislead shall be invalid. The onus for ensuring the full and accurate disclosure of information rests with the applicant.

● I declare that the information given in this document and in all attached forms is true and accurate.

● I declare that I have not made a previous application for validation/recognition as a psychologist in Ireland

I declare that I am eligible to practise as a psychologist in my home country.

● I declare that I have not been found guilty by any statutory registration/licensing body or professional body having jurisdiction in the matter of any professional misconduct within the scope of my profession as a psychologist resulting in the imposition of any suspension, fine, penalty or disciplinary measure.

● I declare that, subject to my qualifications being recognised, I am fit to practise as a psychologist in Ireland.

● I understand that failure to disclose full information, or any deliberate misrepresentation of information, is a serious matter and will invalidate my application.

I understand that I may be required to submit further documentary evidence in support of any particulars given by me on my application form.

I understand that any false, misleading or incomplete information submitted by me will result in the revocation of the recognition of my qualifications.

● I agree to notify the Department of Health in writing, of any change of personal details, e.g. change of surname or address, as and when any such changes occur.

Note: Failure to sign the application form will render it invalid

Name of Applicant: __________________________________________(block capitals)Signature of Applicant:___________________________________________

Date: ___________________________________________

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COMPLETED APPLICATION FORMS, SUPPORTING DOCUMENTATION AND SCRUTINY FEE

BEFORE SUBMITTING YOUR APPLICATION PLEASE ENSURE THAT ALL OF THE FOLLOWING CONDITIONS HAVE BEEN MET

All relevant sections of the application form must be completed in typed text and the form must be signed by the applicant.

All required documentation must be enclosed and clearly referenced to the appropriate section of the application form (incomplete applications may result in an incomplete assessment of your qualifications/work experience).

Do not enclose original documentation.

All supporting documentation must be witnessed as true copies of the originals.

If documents are provided in any language except English, authenticated translations must be supplied in addition to a true copy of the original.

Application form and supporting documentation must be in loose-leaf or as stapled pages; they should not be bound or in cellophane folders.

The scrutiny fee of €500 (cheque, postal order or bank draft) made payable to the Psychological Society of Ireland and drawn on an Irish Bank must be submitted with the completed application.

Applications should be sent to:

Validation UnitDepartment of Health Block 1, Miesian Plaza50 - 58 Lower Baggot StreetDublin 2D02 XW14IRELAND

Notes:1. The Department of Health is the Competent Authority for the assessment of psychology

qualifications and is advised by the Expert Validation Committee (EVC) of the Psychological Society of Ireland (PSI). The Department of Health may contact an applicant during the process. The formal decision will issue from the Department of Health on behalf of the Minister for Health.

2. Recognition of professional qualifications is not to be regarded as an endorsement or a declaration of the applicant’s suitability for employment in any particular post, which is a separate matter for assessment by the employer in the normal way in accordance with the prescribed selection criteria.

3. We recommend that you keep a full record of your application. The Department of Health cannot accept responsibility for any loss that may occur. It will retain documentation on file and cannot photocopy documentation for applicants.

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