I. AGENCY INFORMATION

14 th Street Clinic and Medical Group

Date Completed:

8/1/2005

Address:

1124 International Blvd.

City, State, Zip:

Oakland , CA 94606

Phone:

510-533-0800

Fax :

510-533-0300

Agency Website address:

List multiple agency programs/sites:

Director of Training:

Paul Gaiser, PsyD.

Director Degree and CA License #:

PSY 20325

Director Phone:

510-533-0800

Director email:

P14gaiser@pacbell.net

Other contact person information:

II. PRACTICUM TRAINING PROGRAM BASICS

A. Year Level Openings

Estimated

2 nd Year ( Grad School ) Practicum Openings

3

3 rd Year ( Grad School ) Practicum Openings

3

-Total Practicum Openings

6

-Total Pre-Doc Internship Level Openings

3

B. Students at Agency

Number of Practicum Applicants last year

?

Number of Current Argosy Practicum Students

3

Number of All Current Practicum Students

6

Number of Current Argosy Pre-Doc Interns

Number of All Current Pre-Doc Intern Students

C. Practicum Dates and Times

Beginning Date

July

Ending Date

June

Number of weeks for practicum

50

Hours per week for practicum

20

Required days and times at agency

4 days

5:30 am

D. Stipend : Is there Stipend? If yes, amount per year?

1200/2400

III. AGENCY DESCRIPTION: Please describe below.

A. Population: Indicate estimated % of clients in each category.

%

Gender

%

Life Cycle

55

Male

Infants (0-4)

44

Female

Children (ages 5-12)

1

Transgender:

Adolescents (ages 13-17)

100%

Total

90

Adults (18-64)

10

Seniors (ages 65+)

Ethnic/Cultural Identity

100%

Total

28

African American

8

Asian American

Other Identified Groups

26

Euro-American

10

Gay/Lesbian:

24

Hispanic/Latin American

100

Disabled Population:

4

Native American

International:

10

Other :

Other:

100%

Total

(Note, above will not total 100%)

Populations Treated

88

Individual

Functioning Level of Clients

1

Couples

90

Severe Dysfunction (i.e., psychotic, severe personality or substance abuse dx)

1

Families

10

Moderate Dysfunction (i.e., moderate personality dx, anxiety, depression)

10

Groups

Mild Dysfunction (i.e., adjustment dx, transitions, growth)

100%

Total

100%

Total

? Others notes about populations : Health problems—HIV and HCV

B. Specialty Areas: Mark an X next to all specialties that apply at agency.

X

Behavioral Medicine

Hospital

X

Psychology of Women

X

Health Psychology

X

Community Mental Health Clinic

X

Disabilities

X

Psychopharmacology

Forensics

X

Gay/Lesbian

Pediatrics

Management/Administration

X

Multicultural Therapy

Infant/Parent

Program Evaluation

X

Spirituality/Psychology Integration

Family

Vocational/Career Development

X

Death/Dying/Bereavement

X

Geropsychology

X

Psychological Assessment

X

Domestic Violence

School Based

Neuropsychological Assessment

X

PTSD/Trauma

College Based

X

Psychology of Men

X

Serious Mental Illness

X

Bilingual in treatment

Others (specify): Spanish, others

IV. PRACTICUM TRAINEE RESPONSIBLITIES AND FUNCTIONS

A. Treatment Modalities performed by student: (Mark X in all that apply.)

X

Individual Therapy

X

Crisis Intervention

X

Couples Therapy

X

Brief Therapy

X

Family Therapy

X

Long Term Therapy

X

Group Therapy

X

Psychological Assessment

X

Community Intervention

Neuropsychological Assessment

X

Consultation/Liaison

X

Case Management

X

Others (specify): Charting Progress

? Describe practicum trainee duties and responsibilities :

V. ASSESSMENT and PSYCHOLOGICAL TESTING

A. Assessment Overview

Primarily drug assessment and hx

Will trainee have opportunity for assessment/testing experiences?

yes

Is there additional supervision/training for assessment/testing?

yes

Percentage of practicum time allotted for providing assessment services:

10

Estimate of average # of Test Batteries completed per year:

1-3

B. Assessment Modalities performed by student: (Mark X next to all that apply.)

Projective

Intelligence

Personality

Neuropsychological

X

Academic

X

Vocational

X

Other: ASI Drug Assessment

? Describe the Assessment Program : Primarily drug assessment and history. Student reads about, observes and administers the Addiction Severity Index plus other related tools including formal and informal assessment. Comprehensive history and interview skills are developed and enhanced.

VI. TRAINING/SUPERVISION PHILOSOPHY and OBJECTIVES : A. Please describe below.

Supervision is focused around competencies. Students are assessed and goals set collaboratively, evaluation every 3-4 months. Write evaluation with school sites every 6 months or so.

B. Supervisor Licenses: Please note the number of supervisors with the following licenses.

2

*Licensed Psychologists (PsyD/PhD/EdD)

1

MFT

1/2x

*Psychiatrists

LCSW

X

Other: Post-doc

*Note: Primary Supervisor must be a licensed provider at the doctoral level of training. Primary Supervisor may be individual or group supervisor & must sign or co-sign evaluation forms for students.

C. Supervision and Training

Hours per week

Individual Supervision

1

Group Case Consultation

2

Didactic Training

1.5

Other:

.5

Total hours Training/Supervision

5

D. Methods of Supervision : (Mark X next to all that apply.)

x

Live Observation

x

Process Notes

x

Two Way Mirror

Case Reviews and Discussion

x

Videotapes Review

x

Audiotape Review

Other:

E. Theoretical Orientations of the Supervising Staff (check all that apply)

x

Biopsychosocial

Jungian

x

Cognitive Behavioral

Narrative

x

Family Systems

x

Psychosocial Rehabilitation

Feminist

x

Psychodynamic/analytic

Humanistic/Existential

Transpersonal

x

Integrative

Recovery Based Model

Others (specify):

? Comments on theoretical orientation : Motivational enhancement with the use of stages of change and motivational interviewing.

F. Training Emphasis Areas: Please fill out the following classifications below to assist us in differentiating practicum placements. Indicate with “X” areas where substantial training program and experience exists such that it would qualify for graduate program practicum in these training emphasis areas.

x

Community/Multicultural

x

Cognitive Behavioral

x

Health Psychology

x

Assessment

Forensic Psychology

Geriatric

Family/Child

Gender

Psychodynamic

Not Applicable

x

Others (specify): Drug abuse and Dependency

? Please add specific information regarding all Emphasis Area(s) you checked: Tx involves cts with multiple problems on Axis I primary opiod dependency, 50% psychiatric disorders, 90% health issues (HIV HCV) 50% polysubstance abuse.

VII. PRACTICUM APPLICATION PROCESS FOR STUDENTS

Application Deadline:

April 30

Selection Date Estimate:

May 30 or before

Standard required materials

Vita, Letter of Intent, 3 Letters of Recommendation

Agency specific materials:

Preferred Experience:

Other clinical experience

Preferred Coursework:

Substance abuse and/or addiction

Interview Process: (keep those that apply, erase rest)

Group Interview, Vignettes

Other application/interview information:

VIII. Verifying Information: I verify that the above information is current and accurate.

Date:

8/1/05

Directors Name:

Paul Gaiser, PsyD

*Directors Signature:

PG