Practicum Pre-Screening Form

If you run into any complications with this form, please reach out to our Clinic Manager, Rhian Knowles

hello@squarepegpsychology.ca

Date

Name

Phone number

Email address

Hello and thank you for your interest in a practicum placement with Square Peg Psychology.

We offer a unique placement experience for practicum students. Our practicum placements are entirely virtual, and can therefore be completed from the comfort of a private and secure space in your home anywhere in Edmonton, Alberta or surrounding area.

Our private practice caters mainly to 2SLGBTQIA+ adult clients and clients in non-normative relationships, although we do have a small number of cisgender heterosexual clients as well. You will be supervised by the clinic owner, a Registered Psychologist (Alberta, 2012) who has been supervising students and Provisional Psychologists since 2018.

Due to the virtual nature of the practicum placement, students who are likely to do well will be self-directed, organized, and highly motivated to learn and grow in their clinical skillset.

Please upload a copy of your CV. Please ensure it demonstrates familiarity with the client demographics you would be likely to encounter as a practicum student at Square Peg Psychology.

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Please upload a file

Please upload your cover letter here. Please ensure it is tailored to a practicum placement at this practice and is not a generic cover letter detailing your program requirements.

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I confirm that I have reviewed the Square Peg Psychology website. I confirm that my interests and grounding theories or theoretical models are an appropriate fit as a practicum student being supervised by Susan Larcombe, RPsych.

What theoretical models do you use (or have interest in using) with adults, to conceptualize their case and draw interventions from?

I understand that the clients I work with in practicum will set the tone for at least the early stages of my career as a mental health professional and that I should therefore seek out a practicum setting where I will gain experience working with the types of clients I am passionate about working with.

What client ages do you want to work with during your practicum? Please note I cannot supervise clients who present whose ages fall outside of my scope of competence.

Children

Adolescents

Adults

Which of the following groups of individuals do you have personal and/or professional experience with, in a supportive capacity?

Neurodiverse individuals

2SLGBTQIA+ folks

BIPOC individuals

Differently-abled individuals

Consensually Non-Monogamous individuals

Folks from a different (or non-)religious background to how I was raised

Please provide context for your answers above, regarding diversity.

What client issues do you hope to work with?

Please note I cannot supervise clients who present with issues outside of my scope of competence.

Please outline any trainings you have obtained outside of school specific to client-work? Are there trainings you hope to take during your practicum?

I understand that it is unethical as well as unhelpful to my learning to misrepresent my educational goals for this practicum.

What would you most hope to learn from me as your supervisor if you are successful in your practicum application with Square Peg Psychology?

What aspects of clinical work do you think you will enjoy the most? What aspects do you imagine finding challenging?

What are some traits that you possess that would be an asset to a collaborative supervisor/ supervisee relationship? What do you need from a supervisor to feel supported on your practicum journey?

What would you identify as an area professionally in which you need to grow? How do you plan on addressing this challenge?

Can you give me an example of how you dealt with conflict in a professional setting? Is there anything you would have changed about how you handled the situation?

Thank you so much for the time and reflection you have given to completing this screener.

We will be in touch within 14 business days to schedule an interview if I believe this would be a good fit.

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