Integrated Primary Care Course Interest Form Integrated Primary Care Course Interest Form Please tell us who you are. Faculty in graduate program and/or Clinical Supervisor in a practicum, internship or post doctoral training programGraduate Student, Intern or Post-Doctoral TraineePsychologist in Practice (not faculty, supervisor, or trainee) Faculty/Clinical Supervisor Specific Information Student Specific Information Practicing Psychologist Specific Information Name * Highest Degree * BA/BSMA/MSPhDPsyDother Title/Position * Mailing Address Street * City * State * Zip * Contact Information Phone * Email * Faculty/Clinical Supervisor Questions Please Specify the role in which you plan to use the curriculum: * Faculty in a Graduate ProgramClinical Supervisor of Graduate Students (Check all that apply) * Practicum Students Interns Post-Doctoral Trainees Is your program APA Accredited? YesNoIn Progress How much experience do you have in primary care? None6 months or less6 months to 2 years2-5 years5+ years Which are you? * FacultyClinical Supervisor Does your program offer clinical experience in a primary care setting? YesNo, but plan to startNo, no plans to start How do you intend to use the curriculum? * Full semester courseSelect modules to add to an existing courseColloquia SeriesConduct an independent study course (Choose one) * with one studentwith a group of studentsother (please specify) (Choose one) How do you intend to use the curriculum? * Seminar seriesSelect modules for didactic instructionOther (please specify) How do you intend to use the curriculum? Student Specific Questions Status Graduate StudentInternPost-Doctoral Trainee Institution Is your program APA Accredited? YesNoIn Progress What primary care learning experiences are offered in your training program (select all that apply)? Didactics/Coursework Clinical rotation Primary focus of clinical training It is not currently offered How will you use the materials? Self-studyPeer group learningIndependent study with faculty memberWork with faculty member to establish coursework in my training program Practicing Psychologist Specific Questions Practice Type Independent practiceMultidisciplinary Behavioral Health PracticeHospital/Non-Primary Care Healthcare SettingPrimary CareOther (please specify) Practice Type How will you use the materials? Self-studyPeer group learning How much experience do have in primary care? None6 months or less6 months to 2 years2-5 years5+ years During which of the following was your primary care experience (select all that apply): Graduate School Internship Post-Doctoral Fellowship Post-Graduate (not during training) Not Applicable Terms of Agreement Copyright © 2021 Society for Health Psychology, Division 38 of the American Psychological Association. All rights reserved. I am requesting access to the Integrated Primary Care curriculum as a faculty member of a university graduate program, a clinical supervisor of psychology graduate students in a practicum, internship, or postdoctoral training program, a psychology graduate student (at any level of training), or a licensed psychologist. My intention is to use the curriculum to train my students or for self-study. Materials and resources contained within may not be reproduced, modified, distributed, stored, transmitted, published, or broadcast in any manner without prior written permission. Trademarks, or copyright or other notices, may not be removed from copies of the content. No part of the content (text, image, or video) may be used for any purpose other than the educational terms under which permission was given. Use of content for any commercial purpose is explicitly prohibited. The modules contained within the curriculum are to be distributed to students in ‘READ ONLY’ format. By using these resources, in whole or part, you signify your agreement to all terms, conditions, and notices contained or referenced herein. We reserve the right, at our sole discretion, to update or revise these terms of use. General inquiries regarding terms of use should be directed to the Society for Health Psychology administrative office, accessible from this link. Please Confirm the Terms of Agreement * I affirm that I have the right to enter into this agreement, and agree to the terms outlined. If you are human, leave this field blank. Submit
