Healthcare Psychologist Training Form

HEALTHCARE PSYCHOLOGIST TRAINING FORM

Trainee Information

Date of birth:   Gender:

Program & Supervision

Training site:

Training start date:   Expected completion:

Trainee level (check applicable): Pre-doctoral intern Post-doctoral fellow Practicum student Licensed psychologist Other:

Training Objectives & Scope

Hours & Clinical Experience

Competency Checklist

Check each competency as training components are completed. Where applicable, provide completion date.

Intake assessment and diagnostic formulation — Completed on:

Psychological testing and interpretation — Completed on:

Individual psychotherapy (multiple modalities) — Completed on:

Group therapy facilitation — Completed on:

Crisis intervention and suicide risk assessment — Completed on:

Evidence-based interventions (CBT/DBT/ACT) — Completed on:

Cultural competence and working with diverse populations — Completed on:

Record keeping, documentation standards, and billing compliance — Completed on:

Privacy, Confidentiality & Consent to Supervision

As a trainee I acknowledge that client information obtained during training is confidential. I understand that supervised review of cases, client records, and audio/video recordings is an integral component of training. I authorize my supervisor and program faculty to review and discuss client records, assessment results, and supervision materials for educational and clinical oversight purposes consistent with applicable law and professional ethics.

I understand the limits of confidentiality: information that indicates imminent risk of harm to self or others, suspected abuse or neglect of a vulnerable individual, or court-ordered disclosures must be reported by my supervisor or me in accordance with legal obligations. I will comply with local mandatory reporting requirements and program policy.

By checking the box below I acknowledge that I have read, understand, and agree to comply with the confidentiality terms, supervision procedures, and limits described above.

I acknowledge and agree to the confidentiality and supervision provisions

Recording, Telehealth & Data Security

Recording clinical encounters for supervision or training requires separate client authorization unless otherwise permitted by law. Telehealth delivery must conform to program policies for secure platforms, informed consent, and documentation. Trainees must follow data security protocols and immediately report any breach or inadvertent disclosure to the supervisor.

Recording authorization: Authorized for training/supervision Not authorized

Mandatory Reporting & Emergency Procedures

Trainees must immediately notify their supervisor of any client safety concerns, threats of harm, or situations triggering mandatory reporting. In emergencies follow site protocol; where immediate danger exists contact local emergency services. All subsequent documentation must be timely, factual, and incorporated into the client's record per program policy.

Authorization & Certification

Authorization expiration date for training assignment, if any:

Certification: I certify that the information provided in this form is true and complete to the best of my knowledge. I agree to abide by the training program's policies, applicable laws, and professional ethical standards. I understand that failure to comply with supervision requirements, confidentiality obligations, or scope-of-practice limitations may result in corrective action up to and including removal from the training assignment.

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