Participants in the APPIC Match, including applicants and internship programs, may not communicate, solicit, accept, or use any ranking-related information prior to the release of the Match results.

SECTION 1:  BACKGROUND AND EDUCATIONAL INFORMATION

A. BACKGROUND
 

1. Name:	Sherri A. Sharp (was Galloway)
2. Social Security No:	* Available on Request
3. Match I.D. Number:	#####
4. Home Address:	[withheld from on-line]
5. Work Address:	Educational Psychology Ball State University, Teachers College Muncie, IN 47306
6. Phone (Home):	[withheld from on-line]
7. Phone (Work):	[withheld from on-line]
8. FAX:	[withheld from on-line]
9. E-Mail:	[withheld from on-line]
10. What is your country of citizenship?	U.S.A.
11. Non-citizen visa status:	n/a
12. Is this visa current and valid?	n/a
13. Does visa permit you to work?	n/a
14. Are you a veteran?	n/a
15. On APPIC Match Day, many Internship Training Directors will call the applicants with whom they have been matched.  Please specify the phone number where you may be reached between 11:00 AM and 1:00 PM ET on that day.	[withheld from on-line]

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B. EDUCATION

Current Academic Work
 

1. What is the name and address of the university/institution in which your graduate department is located?	Ball State University Muncie, IN 47306
2. What is the name of your department?	Educational Psychology
3. What is the name of your graduate program?	School Psychology
4. What is the designated subfield of your doctorate in Psychology?	Counseling Neuropsychology Clinical (adult track) Clinical (child track) Clinical (general) School Respecialization Program Developmental Combined Educational Health Other
5. What is your primary theoretical orientation?	Integrative Behavioral Biological Interpersonal Cognitive Behavioral Psychodynamic/Psychoanalytic Eclectic Systems Humanistic/Existential Other
6. What degree are you seeking?	Ph.D. Ph.D./J.D. Psy.D. Certificate/Respecialization Ed.D. Other
7. Name of Training Director:	[withheld from on-line]
8. Training Director E-Mail:	[withheld from on-line]
9. University / School Phone #:	[withheld from on-line]
10. University / School Fax #:	[withheld from on-line]
11. What is the status of your doctoral training program?	APA-Accredited APA-Accredited, on probation CPA-Accredited CPA-Accredited, on probation Not Accredited
12. If not APA / CPA-accredited, is the school regionally accredited?	n/a
13. What is your Department’s Training Model?	Scientist-Practitioner Clinical Scientist Practitioner-Scholar Practitioner Other
14. When did you begin graduate level study in your current program?	08/99
15. When did you complete (or do you expect to complete) your doctoral coursework, excluding dissertation hours?	05/02
16. Have you successfully completed your program’s comprehensive / qualifying examination?	Yes - Date of completion: Due to complete 03/02
17. What is your dissertation / research title or topic?	The Utility of the Dean-Woodcock Structured Interview in Predicting Pathology Measured by the Minnesota Multiphasic Inventory.
18. What type of research is involved in question 17 above?	Use of existing database Critical literature review / theoretical Original data collection Other
19. What is the current status of your dissertation / doctoral research project?	Proposal approved 04/02 Data collected n/a Data analyzed 04/02 Defended 08/02
20. If no dissertation is required, describe the status of any major project:	n/a
21. Name of dissertation / doctoral research advisor:	[withheld from on-line]
22. Phone Number:	[withheld from on-line]
23. E-Mail:	[withheld from on-line]

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Previous Academic Work
 

24. What is the highest degree that you have completed in any mental health field?	B.A. / B.S.
25. When did you complete the above degree?  (Do not respond to this item if this is an undergraduate degree.)
26. Please complete the following table for each undergraduate and graduate  school or university attended:  (list in chronological order)  (Do not complete dates of attendance for undergraduate degree.)	1998 - 1999 M.S. Indiana University Northwest - Secondary Education 1995 - 1998 B.A. Indiana University Northwest - Psychology 1995 - 1997 A.A. Indiana University Northwest - Spanish
27. Licensure / Certification:	n/a
28. Please list any honors received:	School Psychology Assistantship Teaching Assistantship Research Assistantship Dean's List
29. Please list names, addresses, phone numbers, and e-mail addresses of individuals who will be forwarding letters of recommendation:    [withheld from on-line]

 

SECTION 2:  ESSAYS

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1. Please provide an autobiographical statement.

I grew up in Houston, TX and moved frequently to various parts of the city.  Moving around a big city gave me the opportunity to meet different people with extremely diverse backgrounds.  This has helped me to be open-minded and sensitive to individual differences. We later moved to Indiana where I reside now.

My parents are young in age and spirit.  Even though both had full time employment, they always made time to spend with the family, as well as pursue their own interests. My parents are both involved in martial arts, thus when I was 4-years old, I joined also.  I am currently a third degree black belt and have competed both nationally and internationally.  I have also taught in a variety of settings and conducted demonstrations and workshops. Being in martial arts for 20 years has given me the discipline to work hard and endeavor, even in the face of adversity. Competition and teaching has also instilled in me the confidence to face challenges in an adaptive frame of mind.  These personal traits are further evident in my academic achievements of graduating high school early, completing my Masters early while working full-time and earning a place in the Ball State School Psychology Ph.D. program by the age of 22.

The professional employment that I have had while attending university has given me experiences that are valuable to my work in psychology.  During my Bachelor’s Degree, I worked at Swanson Center for Mental Health as the Director's Assistant, which allowed me to function in an outpatient treatment setting around a diverse population interacting with psychiatrists, psychologists, social workers, and other medical personnel.  My time employed at The Training Institute of Indiana, during my Master's Degree, as a caseworker provided me experience collaborating with state agencies, welfare recipients, and their prospective employers.  I currently teach at Sylvan Learning Center and have the opportunity to work closely with individuals of all ages in both one on one and group situations, who have special needs.

I thoroughly enjoy working with children and look forward to the possibility of spending my internship in a highly reputable institution such as UTMB and Shriners Burn Hospital.  I believe that I can grow personally and professionally in such an institution, which treats children and adults, conducts burns and other medical research, and trains medical personnel.

2. Describe your approach to case conceptualization, how your conceptualization informs treatment, and how assessment is linked to your conceptualization and treatment planning.

I believe that one's approach to case conceptualization varies depending upon what type of program you were trained in.  It is also different in various settings.  I have outlined below steps to gaining information, hypothesizing, and diagnosing patients – all part of the conceptualization process.

Coming from a School Psychology background, assessment is an integral part of working with a patient.  When initially assessing a new case, it is important to determine and define the referral question to highlight early on why the patient has been referred by themselves or a healthcare professional.  From this, you can decide upon a direction for your evaluation, specific areas to cover in the clinical interview, and begin to formulate hypotheses.  During the clinical interview, it is important to cover a broad range of areas, as well as asking very specific questions to aid in the development of these hypotheses.  The broad areas to discuss include, but are not limited to, family, developmental, educational, and behavioral history.  I follow this up with correspondence with key figures in the patient's life (e.g., family, teacher, physician).  This enables me to gain a broader, more rounded view of the patient, in various settings.

The next step is to administer various objective and projective measures.  The appropriate tests must be based on what information is deemed needed in order to provide an accurate diagnosis and subsequent treatment.  The results are then used, along with previously gained information, to discount or confirm formerly developed hypotheses.  The information obtained during the evaluation is then used to develop an appropriate treatment plan, recommendations, and interventions to suit the individual's needs.

A similar method is utilized when involved in a counseling relationship.  The information is gained during the sessions.  The diagnosis is based primarily on the client's self-report, as well as observations made during the sessions.  These are compared to the diagnostic criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition.  While formal assessment is not as strongly emphasized in this situation, it can be utilized to obtain information, confirm hypothesis, and assess progress.

3. Please describe your experience and training in work with diverse populations. Your discussion should display explicitly the manner in which multicultural / diversity issues influence your clinical practice and case conceptualization.

Much of what I have learned about various population has been largely informal and firsthand.  As mentioned earlier, living in different areas allowed me to go to school and commune with individuals from different backgrounds, including various cultures, religions, and socioeconomic statuses.  Houston is a diverse city with a predominantly Hispanic population, as such I have personal dealings with many friends and family (my sister-in-law) who are Hispanic.  While working on my Associate Degree in Spanish and learning the language, I was also given insight into the Hispanic culture.  My 20 years in martial arts has provided me with frequent interaction with the Korean community and has afforded me the opportunity to learn more about their culture and history.

Through my teaching, I have had the opportunity to work with children, adults, and families with a range of diversity, including giftedness, learning disabilities, physical handicaps, and environmental obstacles.  Working one-on-one and in group settings has allowed my to see them succeed in many ways.

The formal training that I have received in multicultural issues include a graduate level class focused on the educational, social, and emotional needs of individuals and their families with diverse backgrounds.  I completed my Master's at Indiana University Northwest located in Gary, IN.  The school had a large percentage of African-American and Hispanic populations that I interacted with both in and out of the classroom.  The Ball State University graduate program places a strong emphasis on multicultural issues.  Also, throughout my graduate training in School Psychology, I have focused my professional development toward a pediatric population.  It is often forgotten that children and adolescents are also distinct populations to adults and need to be treated accordingly, not as small adults. While this is not necessarily a multicultural issue, I believe it is an important population distinction to be aware of.

In addition to my academic coursework and research experience, I have developed my assessment skills as an independent diagnostician through my practicum with diverse populations in a variety of settings including the school psychology practicum program, local school corporations (interacting with parents, school personnel, and other professionals), and an outpatient medical agency.  To enhance my skills as a psychologist, I am currently involved in a university and school based practicum in counseling through which am I able to gain valuable therapy experiences with children, adolescents, adults, and families from all cultures, especially low SES, as the program is subsidized.

Through personal interactions and formal training, I have gained an increased awareness of how multicultural awareness influences a wide range of aspects in everyone's lives everyday. Subsequently, clinicians need to mindful, educated and sensitive to individual cultural differences when dealing with patients and family at all levels of care.  I believe that these experiences have positively impacted my clinical practice by assisting me in developing greater multicultural sensitivity and recognizing cultural influences.  I strive to attend to these issues to obtain a more complete case conceptualization, resulting in more appropriate recommendations, interventions, and treatment plans.

4. Please describe your research interests, if applicable.

I am very interested in how play therapy can be utilized to reduce a child's anxiety toward their medical treatment and its integration in rehabilitation.  To date, there is little research on the benefits of using play therapy in relation to physical pain and/or medical treatment.  Potentially, this could be extremely beneficial in a hospital setting such as Shriners’, with burn victims who undergo treatment and rehabilitation that is often very painful. Play therapy could be used to provide these patients with coping skills to better deal with these prolonged experiences.

5. How do you envision our internship site meeting your training goals and interests?

My career and personal goals are to work in a clinical setting with children and conduct research both aimed at assisting children and their families to better cope with the psychological trauma associated with physical injuries, disease, their treatment and rehabilitation.  I believe that the Psychology Resident Program at the University of Texas Medical Branch in Galveston offers me a unique opportunity to further enhance my educational, professional, and research development.  Working as a resident at the University of Texas Medical Branch would afford me the opportunity to work closely with professionals from a variety of disciplines to develop appropriate case conceptualizations, diagnoses, and interventions.  The enjoy working in diversified settings, and so UTMB would allow me to continue to gain more experience working with individuals with a wide range of abilities.  The multidisciplinary approach to assessment and treatment offered by this program will further propagate my understanding of maximum utilization of the resources available to a practitioner in a hospital setting, where I aim to serve.

I am well versed in consultation with parents, teachers, physicians, and professionals from other disciplines, in order to develop a collaborative team that will best meet the needs of each patient.  I have developed interventions to be implemented in the home, school, and work environments.  These interventions have included curriculum modifications for students at both ends of the academic spectrum, home/school behavior modification programs, and psychosocial treatments.  Through consultation with professionals as well as the implementation of interventions, I believe I have the skills and experience academically and clinically in diversified populations in order to contribute as an effective member of the psychology team, in the largely Hispanic patient population at the University of Texas Medical Branch. The urban setting and large Hispanic population of the hospital would also provide me an opportunity to continue to develop my Spanish conversation skills.  The training I have received from an APA approved program in School Psychology based on the scientist/practitioner model has prepared me to utilize my skills in an applied setting as well as engage in and conduct research.

I am excited by the prospect of gaining experience utilizing multiple assessment and treatment approaches through the variety of rotations available at UTMB.  The therapy experiences provided for interns will allow me to hone my skills in individual, group, play, and family therapy.  I am also interested in building upon my skills in consultation, early intervention, and the use of behavior modification.  In addition, gaining new skills in the areas of crisis intervention and services for medical inpatients appeals to me.  A psychology internship within this setting would fit well with my career aspirations as a clinical and research psychologist.
 

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	DOCTORAL
a. Individual Therapy	Total hours face-to-face	# of different individuals
1) Older Adults (65+) 2) Adults (18-64) 3) Adolescents (13-17)  4) School-Age (6-12) 5) Pre-School Age (3-5)  6) Infants / Toddlers (0-2)	n/a 10 n/a 5 n/a n/a	n/a 1 n/a 1 n/a n/a
b. Career Counseling
1) Adults 2) Adolescents	n/a n/a	n/a n/a
c. Group Therapy	Total hours face-to-face	# of different groups
1) Adults  n/a n/a 2) Adolescents (13-17)  3) Children (12 and under)	n/a Group Developer 5	n/a 1 1
d. Family Therapy	Total hours face-to-face	# of different families
Family Therapy	5	1
e. Couples Therapy	Total hours face-to-face	# of different couples
Couples Therapy	n/a	n/a
f. School Counseling Interventions	Total hours face-to-face	# of different individuals
1) Consultation  50 5 2) Direct Intervention  25 5 3) In-Services  5 3	50 25 5	5 5 3
g. Other Psychological Interventions
1) Sports Psychology / Performance Enhancement	n/a	n/a
2) Medical / Health - Related Interventions	n/a	n/a
3) Intake Interview /  Structured Interview	30	30
4) Substance Abuse Interventions	n/a	n/a
5) Other interventions	5	5
Please describe the nature of the experience(s) listed in g-5:	1. Working with patient to develop goals of counseling and steps to achieve. 2. Working with parents, teacher, and children to develop and implement behavior modification plans.

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h. Psychological Assessment Experience:	DOCTORAL  Total hours  -  face-to-face
1) Psychodiagnostic test administration (Include symptom assessment, projectives, personality, objective measures, achievement, intelligence, and career assessment), and providing feedback to clients/patients.	350
2) Neuropsychological Assessment (Include intellectual assessment in this category only when it was administered in the context of neuropsychological assessment.)	150
* Age Groups served:	Adults (18-64) Adolescents (13-17) School-Age (6-12) Pre-School Age (3-5)
i. Other Psychological Experience with Students and/or Organizations:
1) Supervision of other students	5
2) Program Development/Outreach Programming	10
3) Outcome Assessment of programs or projects	10
4) Systems Intervention / Organizational Consultation / Performance Improvement	2
5) Kindergarten Screening	20
6) Attending Professional Psychology Conferences	30

	DOCTORAL Total hours face-to-face	MASTERS Total hours face-to-face
TOTAL INTERVENTION AND ASSESSMENT HOURS:	717	n/a

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2. SUPPORT ACTIVITIES – How much time have you spent in support activities related to your intervention and assessment experience?
 

	DOCTORAL Total hours	MASTERS Total hours
Total Support Hours:	400	n/a

3. SUPERVISION RECEIVED – How much time have you spent in supervision?
 

	DOCTORAL Total hours
a. Hours spent in one-on-one, face-to-face  supervision:	85
b. Hours spent in group supervision:	130
c. Hours of peer supervision / consultation  and case discussion on specific cases:	90
Total Supervision Hours (add 3a, 3b, and 3c):	305

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4. SUMMARY OF PRACTICUM HOURS -
 

	DOCTORAL Total Hours through  Nov. 1, 2001	DOCTORAL Hours Estimated after Nov. 1, 2001
a. Total Intervention and Assessment  Hours (item 1):	717	200
b. Total Support Hours (item 2):	400	180
c. Total Supervision Hours (item 3):	305	65
Grand Total	1422	445

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5. TREATMENT SETTINGS - How many practicum hours have you spent in each of the following treatment settings?
 

	DOCTORAL Total hours
Child Guidance Clinic	5
Community Mental Health Center	n/a
Department Clinic (psychology clinic run by a department or school)	1187
Forensic / Justice setting (e.g., jail, prison)	n/a
Inpatient Hospital	n/a
Military	n/a
Outpatient Medical / Psychiatric Clinic & Hospita	40
University Counseling Center / Student Mental Health Center	n/a
Schools	230
Other  (Specify:)	n/a
Total Hours in all Treatment Settings	1422

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6. OTHER INFORMATION ABOUT PRACTICUM EXPERIENCES:
 

a. What types of groups have you led or co-led?  Please describe.	Social Skill Streaming, Co-Leader Sexually Abused Adolescent Girls Group, Group Developer & Process Observer Group for Preschool Children with Emotional Handicaps, Received training Group for Adults with Alcohol Dependency, Will be starting soon
b. Do you have experience with Managed Care Providers in a professional therapy / counseling / assessment capacity?	Yes
c. Have you audio or videotaped clients/patients and reviewed these tapes with your clinical supervisor?	Audio tape review - Yes Videotape review - Yes
d.  In which languages other than English (including American Sign Language), are you FLUENT enough to conduct therapy?	While I can read and speak Spanish conversationally, I am not fluent enough to feel comfortable conducting therapy.
e. What is your experience with diverse populations in a professional therapy / counseling capacity?  Please indicate the number of clients/patients seen for each of the following diverse populations.  You may provide additional information or comments in the space provided.  Include clients/patients for whom you performed assessments or intake interviews.  For this item, you may include a single client/patient in more than one category, as appropriate.
Race / Ethnicity	Number of Different Clients / Patients Seen
African-American / Black / African Origin	5
Asian-American / Asian Origin / Pacific Islander	5
Latino-a / Hispanic	6
American Indian / Alaska Native / Aboriginal Canadian	n/a
European Origin / White	44
Bi-racial / Multi-racial	6
Sexual Orientation (Included children whose sexual preference was unknown in the heterosexual category)
Heterosexual	65
Gay	n/a
Lesbian	n/a
Bisexual	1
Disabilities
Physical / Orthopedic Disability	3
Blind / Visually Impaired	n/a
Deaf / Hard of Hearing	1
Learning / Cognitive Disability	12
Developmental Disability	5
Serious Mental Illness (e.g., primary psychotic disorders, major mood disorders that significantly interfere with adaptive functioning, severe developmental disabilities)	3
Other (specify)	18 Attention Deficit Hyperactivity Disorder Encopresis Enuresis Fetal Alcohol Syndrome Generalized Anxiety Disorder Gifted Narcolepsy Neurological Impairment Oppositional Defiant Disorder Separation Anxiety
Gender
Male	36
Female	30
Transgendered	n/a

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7. TEACHING EXPERIENCES - What is your teaching experience?

I was awarded a teaching assistantship for one year.  I worked with Dr. ***** for the Behavior Analysis course that he taught.  I proctored exams and taught several classes for this graduate level course.  I also assisted Dr. ***** in his preparation for classes.

I have taught at Sylvan Learning Center for the last 2 years.  There I have the opportunity to work with young children through adults with a wide range of abilities.

I have been a martial arts instructor for the last 14 years.  I have taught in one-on-one, small group, and large class settings.  Through martial arts instruction, I have worked with individuals with various disabilities, learning styles, and levels of motivation.  I also teach the Tae Kwon Do class each semester for Ball State University and have helped with several classes at Indiana University Northwest.

8. CLINICAL WORK EXPERIENCES – What other clinical experiences have you had?

Employment during my time in university has provided me with experiences that I did not receive in my practicums.  These experiences have played a part in the well-roundedness of my professional skills.  I have had the opportunity to conduct career counseling for individuals with a variety of interests and skills.  I have also been able to help clients with job search and interviewing skills.  In another arena, I have been involved in drug awareness training programs for adolescents, as well as self-defense classes.

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What is your experience with the following instruments?
 

1. ADULT TESTS
Name of the Test	# Administered and Scored	# of Reports Written
Self-report measures of symptoms / disorders  (e.g., Beck Depression Inventory)	n/a	n/a
Bender Gestalt	n/a	n/a
Trail Making Test A & B	2	2
WAIS-III	4	4
Wechsler Memory Scale III	1	1
MMPI-II	3	3
Millon Clinical Multi-Axial Inv. III (MCMI)	1	n/a
Personality Assessment Inventory	1	n/a
Rorschach	n/a	n/a
TAT	1	1
Projective Sentences (includes Rotter Sentence Completion and other Sentence Completion Tests)	n/a	n/a
Projective Drawings (includes Draw-a-Person Test and Kinetic Family Drawing Test)	n/a	n/a
Myers-Briggs Type Indicator	1	n/a
Strong Interest Inventory	n/a	n/a
Structured Diagnostic Interviews (e.g., SADS, DIS)	5	5
Other Tests: College Adjustment Scale	1	1
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2. CHILD AND ADOLESCENT TESTS
Name of Test	# Administered and Scored	#of Reports Written
Connors Scales (ADD assessment)	1	1
MMPI-A	3	3
Rorschach	n/a	n/a
Peabody Picture Vocabulary Test	n/a	n/a
Self report measures of symptoms / disorders (e.g., Children’s Depression Inventory)	6	6
Parent Report Measures (e.g., Child Behavior Checklist )	7	7
Diagnostic Interviews (e.g.,  DISC, Kiddie-SADS)	5	5
WISC-III	7	7
WPPSI-R	2	2
WRAT	8	8
Other Tests: Behavior Assessment Scale for Children – Teacher	6	6
Bracken Basic Concept Scale – Revised	21	1
California Verbal Learning Test – Child	1	1
Clinical Evaluation of Language Fundamentals – Preschool	1	1
Cognitive Assessment System	2	2
Differential Ability Scales – Achievement	4	4
Differential Ability Scales – Cognitive	5	5
Differential Ability Scales – Preschool	1	1
Kaufman Adolescent Intelligence Test	2	2
Kaufman Brief Intelligence Test	1	1
Kaufman Test of Educational Achievement	2	2
Peabody Intellectual Aptitude Test	3	3
Student Styles Questionnaire	5	5
Test of Nonverbal Intelligence	1	1
Universal Nonverbal Intelligence Scale	1	1
Vineland Adaptive Behavior Scale – Classroom	1	1
Wecshler Individual Achievement Test	10	10
* Tests for Children through Adults
Boder Test of Reading-Spelling Patterns	1	1
Dean-Woodcock Neuropsychological Battery	16	5
Developmental Test of Visual-Motor Integration	10	0
Halstead-Retain Neurological Assessment System	2	1
House-Tree-Person/Kinetic Family Drawing	10	10
Stanford-Binet Intelligence Scale - IV	5	0
Woodcock-Johnson – III, Achievement	2	2
Woodcock-Johnson – Revised, Achievement	7	7
Woodcock-Johnson – Revised, Cognitive	7	7

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3. INTEGRATED REPORT WRITING
 

How many supervised integrated psychological reports have you written for each of the following populations?
a. Adults:	10
b. Children / Adolescents:	25

 
 

SECTION 5:  PROFESSIONAL CONDUCT

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1. Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor, educational or training institution, health care institution, professional association, or licensing / certification board?	NO
2. Are there any complaints currently pending against you before any of the above bodies?	NO
3. Has there ever been a decision in a civil suit rendered against you relative to your professional work, or is any such action pending?	NO
4. Have you ever been suspended, terminated, or asked to resign by a training program, practicum site, or employer?	NO
5. Have you ever been convicted of an offense against the law other than a minor traffic violation?	NO
6. Have you ever been convicted of a felony?	NO

 

SECTION 6:  APPLICATION CERTIFICATION

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I certify that all of the information submitted by me in this application is true to the best of my knowledge and belief.  I understand that any significant misstatement in, or omission from, this application may be cause for denial of selection as an intern or dismissal from an intern position.  I authorize the internship site to consult with persons and institutions with which I have been associated who may have information bearing on my professional competence, character, and ethical qualifications.  I release from liability all internship staff for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications.  I also release from liability all individuals and organizations who provide information to the internship site in good faith and without malice concerning my professional competence, ethics, character, and other qualifications.

If I am accepted and become an intern, I expressly agree to comply fully with the Association of Psychology Postdoctoral and Internship Centers (APPIC) policies, the Ethical Principles of Psychologists and Code of Conduct and the General Guidelines for Providers of Psychological Services of the American Psychological Association, and with the standards of the Canadian Psychological Association which are applicable.  I also agree to comply with all applicable state, provincial and federal laws, all of the Rules and Code of Conduct of the State or Provincial Licensing Board of Psychology, and the rules of the institution in which I am an intern.

I understand and agree that, as an applicant for the psychology internship program, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications.

PLEASE REFER TO ATTACHMENTS: Application Certification

Applicant’s Signature:   Sherri A. Sharp

Date:   10/30/01

1. Applicant’s Name:		Sherri A. Sharp (was Galloway)
2. Doctoral Program / Department:		School Psychology Program Educational Psychology Department
3. University / School:		Ball State University
4. Director of Training:		[withheld from on-line]
5. Director of Training’s Address, Phone, and E-Mail:		Educational Psychology Teachers College, 5th Floor Muncie, IN 47306	[withheld from on-line]
6. Academic Requirements:	Date Completed or Expected (mm / yyyy)	Required to accept an internship?	Required to attend an  internship?
a. Comprehensive / Qualifying Exam / Task	03/02	No	Yes
b. Academic Coursework	05/02	No	Yes
c. Master’s Thesis	n/a	n/a	n/a
d. Dissertation / Doctoral Research Project
Proposal approved	04/02	No	Yes
Data collected	n/a	n/a	n/a
Data analyzed	04/02	No	No
Defended	08/02	No	No
7. Practicum Hours:	Doctoral through Nov. 1, 2001	Masters	Estimated after Nov. 1, 2001
a. Total Intervention and Assessment Hours (item 1):	717	n/a	200
b. Total Support Hours (item 2):	400	n/a	180
c. Total Supervision Hours (item 3):	305	n/a	65
GRAND TOTAL	1422	n/a	445

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PLEASE REFER TO ATTACHMENTS: Verification P1, Verification P2, Verification P3

8.  Academic Standing:
9.  Department’s Training Model:
10.  APA / CPA Accreditation:
11. Evaluation of Applicant:
12. Additional comments:
13. The faculty agrees that this student is ready to apply for internship.
14. Once the student is on internship:

 Date signed:  _______________