1. Applicant Information

Applicant Name: *  

Date of Birth:

Residential Information Business Information
Home Address: *  
Business Address:
City: *  
Province/State: *  
Postal/Zip Code: *  
Postal/Zip Code:
Country: *  


Home Phone: *  
Telephone (Bus):
Cell Phone (optional):
Email: *  
Preferred Mailing Address:

2. Training Opportunities: Please rank in order of preference only those areas of interest

Outpatient Services
Includes: Outpatient General Adult Track, Borderline Personality Self-Regulation Clinic, The Traumatic Stress Clinic, Transitional Aged Youth Clinic


Assessment & Reintegration Program - Inpatient General Adult Track
Includes: Assessment Stabilization Unit (ASU), Psychiatric Rehabilitation A (PRA), Young Adults Transitional Service (YATS)

Geriatric and Neuropsychiatry Program

Outpatient Service
Includes: Memory Clinic, Geriatric Mental Health Clinic, Neuropsychiatry Clinic

Inpatient Service
Includes: Geriatric Dementia Unit, Geriatric Psychiatry Unit, Neuropsychiatry Service


Adolescent Program
Includes: Adolescent Outpatient Service (AOP), Adolescent Inpatient

Forensic Program

Outpatient Service
Includes: Forensics Outpatients

Inpatient Service
Includes: Forensics Inpatients

3. List below all the psychological assessment instruments you have experience in: administration, scoring, and interpretation.

Domain Name of Test Number of Tests Administered Number of Tests Scored Number of Tests Interpreted

Cognitive, Intellectual Wechsler Adult Intelligence Scales (WAIS-IV)
Wechsler Intelligence Scale for Children (WISC V)
Wechsler Individual Achievement Test
Wide Range Achievement Test (WRAT-IV)

Memory Wechsler Memory Scales (WMS-III; IV)

Neuropsychological Delis-Kaplan Executive Function Scales
Halstead-Reitan Battery
Kaplan Process Battery

Personality Minnesota Multiphasic Personality Inventory -
Restructured (MMPI-2-RF)
  Personality Assessment Inventory (PAI)
  Personality Assessment Inventory - Adolescent (PAI-A)
Millon Clinical Multiaxial Inventory (MCMIV)

Structured Clinical Interview Structured Clinical Interview for DSM-5
DSM-5 - Personality Disorder
Kiddie-Schedule for Affective Disorders (K-SADS) for DSM-5

Symptom Rating Scales Children's Behavioural Checklist (CBCL)
Positive and Negative Symptoms Scale (PANSS)
Trauma Symptom Inventory (TSI)

Depression/Anxiety Beck Depression Inventory (BDI-II)
Beck Anxiety Inventory (BAI)

Risk Assessment Forensic Historical Clinical Risk Guide (HCR-20 V3)
Psychopathy Checklist Revised (PCL-R Revised 2nd Edition)
Risk for Sexual Violence Protocol (RSVP)

Please list other tests that you have experiecne with that do not appear above
Domain Name of Test Number of Tests Administered Number of Tests Scored Number of Tests

4. Clinical Treatment Experience:

Please indicate the number of clients you have seen in each column according to treatment modality, individual versus group and length of treatment
ModalityNumber of Individual Clients Number if Group Clients Number of
(≤ to 12 Sessions)
Number of Long-Term
(> 12 Sessions)
Cognitive Behavioural Therapy
Dialectical Behaviour Therapy (DBT)
Psychodynamic Therapy
Interpersonal Psychotherapy
Client-centered Therapy
Marital/Couples Therapy
Family Therapy
Emotion Focused Therapy
Rehabilitation Counselling
Other (please specify):        

Please indicate the number of clients you have seen in each column according to age and diagnosis:

 Child Adolescent AdultGeriatric
Anxiety disorders
Cognitive Disorders
Eating Disorders
Mood Disorders
Personality Disorders
Pervasive Developmental Delay
Psychotic Disorders
Sexual Disorders
Substance Use Disorders
Forensic Clients        
Other (please specify)        

5. Educational Background

University *   Date of Attendance Major Degree Granted APA/CPA Accredited

6. List Previous Practicum (if applicable)

Location Date Attended Supervisor Assessment Therapy

7. Letters of Reference will be sent from the following (list two)

Name Address Telephone Email


Preference will be given to applicants enrolled in CPA or APA accredited programs, although applicants from nonaccredited programs will also be considered.

Application Procedure Checklist

Applications for Ontario Shores Practicum in Psychology must include:

  • Ontario Shores-specific application form
  • letter stating areas of interest and goals
  • Curriculum Vitae
  • An undergraduate and graduate transcipt
  • Two letters of reference (originals in signed/sealed envelopes)

Please direct completed applications (or inquiries) to:

Erica Francis
Coordinator, Student Affairs
Ontario Shores Centre for Mental Health Sciences
700 Gordon Street.
Whitby, ON L1N 5S9
Phone: 905-430-4055
Fax: 905-665-2458

Completed applications should be received no later than February 1. However, late applications may be accepted if spots
are still available. We abide by the Ontario-wide Practicum notification procedures.


If successful, candidate will require the following before placement can commence:

  • An original copy of the Criminal Record Check (CPIC) with vulnerable sector screening (no older than six months prior to placement). Failure to present your CPIC could result in a delay in the start date of your practicum placement. Please note: It can take anywhere from 4-12 week to obtain the CPIC from your local police department.
  • Applicant must be up-to-date with their immunizations (Hep B, measles, mumps, rubella, varicella immune status, TB results (2-step and yearly) and TdP status
  • WEA form (Workplace Education Agreement (available from your university/college)
  • Affiliation agreement between university/college and Ontario Shores, and a Certificate of Insurance must be in place prior to placement.



Personal information you provide to Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is collected pursuant to the Public Hospitals Act R.S.0 1990, c. P.40. It will be used for the purpose of determining eligibility for placement at Ontario Shores and administering placement services. At all times it will be treated in accordance with the provisions of the Freedom of Information and Protection of Privacy Act. If you have questions about the collection of your personal information, please refer to the Privacy & Access pages on the Ontario Shores website or contact the Leader, Privacy & Access at 700 Gordon St. Whitby, ON L1N 5S9; 905-430-4055 ext. 6712.