Personal Information

Highest Degree Achieved

Please indicate below those courses of study that you have completed and/or attended that are relevant to your preparation as a trainee/student at The Family Institute of Neve Yerushalayim:

Psychopathology

Yes No

Course Equivalent Psychopathology

Institution Attended Psychopathology

# of Hours/Grade Psychopathology

Date Completed Psychopathology

Couples Therapy

Yes No

Course Equivalent Couples Therapy

Institution Attended Couples Therapy

# of Hours/Grade Couples Therapy

Date Completed Couples Therapy

Human Development/Life Cycle

Yes No

Course Equivalent Human Development/Life Cycle

Institution Attended Human Development/Life Cycle

# of Hours/Grade Human Development/Life Cycle

Date Completed Human Development/Life Cycle

Family Systems/Family Therapy

Yes No

Course Equivalent Family Systems/Family Therapy

Institution Attended Family Systems/Family Therapy

# of Hours/Grade Family Systems/Family Therapy

Date Completed Family Systems/Family Therapy

Do you have at least one year of supervised clinical experience in either an internship/practicum or similar framework?

Yes No

Date of Clinical Experience 1

Organization/Agency 1

Name of Supervisor 1

Brief description of clinical experience, caseload, population and issues 1

Date of Clinical Experience 2

Organization/Agency 2

Name of Supervisor 2

Brief description of clinical experience, caseload, population and issues 2

English