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APPLICATION FOR PROFESSIONAL PROGRAMME IN CLINICAL ANDCOUNSELLING PSYCHOLOGY 2017
Surname: / Date of Birth:
Name: / Age:
Telephone/ Cell: / Insert your photograph here:
Email:
Postal Address:
Which course do you intend to apply for?
You are required to choose ONLY ONE / CLINICAL
Code: 8815 / [1]COUNSELLING
Code: 8815
Name and telephone number of friend or relative that we can contact if we are unable to reach you:
Do you have a foreign qualification?
If Yes, is the qualification SAQA approved?
Indicate the nature of your foreign qualification? / YES
YES / NO
NO
Have you applied for a place in this course before? If so, at which university and which year/s did you apply?
How are you planning to fund your studies, if selected?
PERSONAL DETAILS
[2]Race / Black / White / Indian/Asian / Coloured
Gender
Nationality
Relationship Status:
Do you have any disability that may impact on your training: / Yes / No
If Yes, what is the nature of your disability:
What reasonable accommodation would you require if selected?
Do you have any dependent children?
Provide details (i.e. number of & age of children): / Yes / No
Do you have any dependent adults that require care? Provide details : / Yes / No
Are you currently employed? / Yes / No
Medical history: Please indicate relevant conditions, incidents, etc.
Psychological history:
Please indicate your proficiency in the following languages by using the ratings: good/average/weak/none
Language / Understand / Speak / Write
English
isiXhosa
isiZulu
Afrikaans
Other South African Languages
ACADEMIC DETAILS
UNDERGRADUATE PSYCHOLOGY RESULTS
Year / University / Average marks for psychology (calculate the aggregated mark for your Psych 1, 2, and 3 credits) / %
Psychology 1 (Average of all Psychology 1 modules)
Psychology 2 (Average of all Psychology 2 modules)
Psychology 3 (Average of all Psychology 3 modules)
Psychology 4 (If you completed a B.Psych Equivalent degree)
POSTGRADUATE PSYCHOLOGY RESULTS
What is the status of your Psychology Honours Degree? / Current / Completed
Year:
If you are currently enrolled for Honours, indicate at which University:
Year / University / Psychology Honours Modules / %
Overall Result (%)
Have you completed any of the following Psychology Honours Modules:
Module / Yes / No
1 / Psychopathology
2 / Psychological Assessment/Psychometry
3 / Personality theory
4 / Research Psychology
5 / Counselling skills
6 / Community Psychology
Honours/B.Psych Equivalent Practicum
Have you completed a Hons/B. Psych. Equivalent Practicum?
Through which University did you complete your Practicum?
Indicate the name of the Practicum site?
Which year did you complete your Practicum?
Have you written the Board Exam?
Were you successful in terms of the Board Exam?
Please indicate any other Postgraduate qualifications that you have
Year / University / Course (e.g. MA, PHD, Post-graduate diploma)
Include in your application your full academic record detailing the other courses that you completed.
RELEVANT LIFE EXPERIENCES
Provide an indication of your life experiences relevant to the field of psychology. Reflect on how these life experiences have shaped your thinking about clinical training in psychology and potentially prepared you for such training. Please do not exceed the space limit provided.
Personal psychotherapy / Please indicate if you have been involved in personal psychotherapy & reflect on how this has shaped your thinking about clinical training in psychology and potentially prepared you for such training.
Training courses and workshops attended / Indicate if you have participated in any training courses/workshops relevant to psychology & reflect on how this has shaped your thinking about clinical training in psychology and potentially prepared you for such training.Also indicate the year you attended the workshop/course.
Leadership Experience / Indicate your leadership experiences & reflect on how this has shaped your thinking about clinical training in psychology and potentially prepared you for such training.
OCCUPATIONAL EXPERIENCE
Indicate your occupational experience and whether this was undertaken on a full time, part time or voluntary basis
Year / Position/Type of work that you did / Part time, Full time or Voluntary
APPLICANTS WITH FOREIGN NATIONAL STATUS
If you are foreign national, please provide the following information / Yes/No
Have you obtained a foreign qualification? If yes, please specify
Has it been SAQA assessed?
Has it been SAQA approved?
Do you have SA permanent residency status?
Please specify the nature of your VISA? ______
Indicate VISA expiry date?
Please submit relevant documentation
Details of 3 Referees
Referees name / Telephone & Email / Capacity
(In what capacity does this person know you?)
Note: You are required to send each of your referees the Confidential Referee Report Form. Your referees must submit the referee report form prior to the closing date for applications (31st May 2017). It is your responsibility to ensure that each of your referee reports reach us.
ATTACHMENTS
PLEASE ATTACH THE FOLLOWING INFORMATION TO YOUR APPLICATION.
YOU ARE REQUIRED TOADHERE TO THE PRESCRIBED WORD LIMIT.
(Ms Word, Font: Times New Roman, Font size 12, Spacing: 1,5)
1 / Confidential Autobiographical Essay
In exactly one page (500 words), write a personal account of your life story that includes important life experiences, formative influences and your interests and activities.
2 / Statement of Motivation
In 250 words explain what motivates you to follow a career in either Clinical or Counselling Psychology?
3 / Reflection on previous selection processes (if applicable)
If you have applied for this course previously and were unsuccessful, please provide details regarding your experience of the process and how you have incorporated the experience to enhance your eligibility as an applicant (250 words).
4 / Relevance of Psychology in South Africa
In 250 words,identify an issue relevant to South African society and describe the role of psychology in terms of this issue.
5 / Important Relationships
In 250 words, describe some of the relationships that are important to you. Who provides you with emotional support? If selected, how would these relationships and support be impacted?

I hereby declare that the above information is correct.

Full name: ______

Signature: ______

Date: ______

[1] Counselling Psychology will only be offered in 2018 if final accreditation is received from the HPCSA.

[2] For purposes of training/employment equity