Application for the abn diploma



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APPLICATION FOR THE ABN DIPLOMA
I hereby make voluntary application to the American Board of Professional Neuropsychology for the issuance of a diploma and submit information in support of my candidacy.
Please type or print clearly. Submit the fully completed application to the ABN Application Coordinator by fax, e-mail or mail. See the web site for instructions: www.abn-board.com


Home Contact Information:

Name:

     

Address:

     

City:

     

State/Zip:

     

Phone:

     

Email:

     




Business Contact Information:

Employer/Practice:

     

Address:

     

City:


     

State/Zip:

     

Phone:

     

Email:

     



Professional Licensure: (please enclose photocopy of current licenses)


License Number:

Date Issued:

State:

     

     

     

     

     

     

     

     

     



Board Certifications (e.g. ABPdN, ABPP)

Specialty Area

Certificate #

     

     

     


     

     

     

     

     

     

     

     

     




Respecialization in Clinical Neuropsychology (please request that registrar forward official transcripts)

Did you complete a formal respecialization certificate program in neuropsychology after obtaining graduate training in another specialty area of practice?

Yes/No



Program:      

Year completed:      


Graduate education in psychology: (please request that registrar forward official transcripts)


Institution

Major Specialization in Psychology

Degree

Date


APA/CPA accredited

     

     

     

     

Yes/No



     

     

     

     

Yes/No



     

     

     

     

Yes/No



Note: Graduates of non APA/CPA accredited programs may demonstrate equivalency of doctoral training via listing in ASPPB/National Register Joint Designated Programs, by credentialing in the most recent directory of the National Register of Health Service Psychologists, or Canadian Register of Health Service Psychologists, or possession of the Certificate of Professional Qualification in Psychology issued by the Association of State and Provincial Psychology Boards (ASPPB CPQ)



If your doctoral program was not APA/CPA accredited, is it an ASPPB/National Register


Joint Designated Program?

http://www.nationalregister.org/resources-links/doctoral-programs/approved-doctoral-programs-by-jurisdiction/


Yes/No


Are you credentialed by any of the following organizations?





Certificate #

(please enclose copy)



  • National Register of Health Service Psychologists

Yes/No



     

  • Canadian Register of Health Service Psychologists

Yes/No



     

  • Association of State and Provincial Psychology Boards

Certificate of Professional Qualification in Psychology (ASPPB-CPQ)

Yes/No



     




Pre doctoral Internship

Training Site


Primary Supervisor

Dates

Accreditation

     

     

     

APA CPA APPIC listed

     

     

     

APA CPA APPIC listed

     

     

     

APA CPA APPIC listed




If you did not complete an  APA  CPA  APPIC listed internship, please choose one of the following:

My internship meets National Register of Health Service Psychologists guidelines as demonstrated by my active National Register membership https://www.nationalregister.com/Find/AdvancedSearch.aspx

Yes/No


OR: I have forwarded the ABN Internship Guidelines Verification to my internship supervisor(s) for completion.


Yes/No



Note: Candidates who did not complete an APA / CPA accredited, or APPIC-listed internship, and who are not credentialed by the National Register, may request that their internship supervisor(s) verify equivalency of their internship experience to National Register guidelines, by completing and returning the ABN Internship Guidelines Verification.




Post Doctoral Training in Neuropsychology

Site

Primary Supervisor

Dates

Accreditation




     

     

     

APA APPCN

AABN APPIC listed






     

     

     

APA APPCN

AABN APPIC listed




     

     

     

APA APPCN

AABN APPIC listed







Requirements specific to era of graduation (Refer to ABN Specialty Specific Requirements, for additional detail)

On or after January 1, 2005: Completion of the equivalent of 2 years of full-time postdoctoral education and training, on at least a half-time basis, that closely follows Houston Conference guidelines is required. Completion of a formal 2 year postdoctoral training fellowship, such as those offered by APPIC or AABN, is preferred but not required.

  1. If you are a US trained applicant whose post doctoral training was completed at a non APA / AABN / APPCN / APPIC-listed program, have you requested that post doctoral supervisor(s) complete the Post Doctoral Training Verification form documenting that post doctoral experiences closely followed Houston Conference guidelines?
    (Canadian trained applicants; see Canadian Guidelines section of ABN Specialty Specific Requirements.)


Yes/No


Between January 1, 1990 and December 31, 2004: Two or more years of supervised training in the application of clinical neuropsychological services, with participation in specialty-specific didactics is required. At least one year of training must be postdoctoral.

  1. How many years of clinical neuropsychological experience supervised by a clinical neuropsychologist including participation in specialty specific didactics have you received at the post doctoral level?



  1. What proportion of internship year, if any, was devoted to clinical neuropsychology practice, supervision, or didactics? (Training in neuropsychology at the internship level is not required, but may apply toward partial fulfillment of neuropsychology training requirements for applicants who graduated prior to 2005. Please describe in detail in the Applicant Narrative accompanying this application)

      years
      %

Between January 1, 1982 and December 31, 1989: 1600 hours of clinical neuropsychological experience supervised by a clinical neuropsychologist at the predoctoral or postdoctoral level is required.
  1. How many hours of clinical neuropsychological experience supervised by a clinical neuropsychologist did you obtain at the predoctoral level?




  1. Approximate number of predoctoral internship hours devoted to clinical neuropsychology practice, supervision, or didactics. (Training in neuropsychology at the internship level is not required, but may apply toward partial fulfillment of neuropsychology training requirements for applicants who graduated prior to 2005. Please describe in detail in the Applicant Narrative accompanying this application)

      hours
      hours

Before 1982: 4800 hours of postdoctoral experience in a neuropsychological setting, involving a minimum of 2400 hours of direct clinical service is required.

  1. Total hours of postdoctoral experience obtained in a neuropsychological setting?

  2. Total postdoctoral hours providing direct clinical neuropsychological service?

(Please describe in detail in the Applicant Narrative accompanying this application)

      hours

      hours



Note: Senior Applicants (graduating prior to 2005) need not submit Post Doctoral Training Verification. However, a detailed description of the cumulative training experiences contributing to completion of requirements specific to your graduation era should be included in the Applicant Narrative accompanying this application.


If post doctoral training was completed at an APA / AABN / APPCN accredited site: GO DIRECTLY TO PAGE 5


Specialty-Specific Education and Training:

Note: Applicants who did not complete postdoctoral training with an APA accredited, AABN or APPCN member program are requested to document relevant coursework, didactic and experiential training in the topic areas listed below. Some requirements may be fulfilled by less formal means (e.g., for Clinical Neurology, Neurology Grand Rounds is acceptable, while completion of a Brain Cuttings Seminar or National Academy of Neuropsychology DistanCE Learning course may be credited toward Neuroanatomy training guideline), but please describe in every case.

Basic Neurosciences

Title / description of training experience

Instructor or learning method

Setting

Date

     

     

     

     

     

     

     

     

     

     

     

     

Clinical Neuropsychological Assessment


     

     

     

     

     

     

     

     

     

     

     

     

Neuropathology

     

     

     

     

     

     

     

     

     

     

     

     

Clinical Neurology

     

     

     

     

     

     

     

     

     

     


     

     

Psychological Assessment

     

     

     

     

     

     

     

     

     

     

     

     

Psychological Intervention

     

     

     

     

     

     

     

     

     

     

     

     

Neuroanatomy

     

     

     

     

     

     


     

     

     

     

     

     

Psychopathology

     

     

     

     

     

     

     

     

     

     

     

     



Professional experience: (please enclose curriculum vita and professional narrative)

Number of years of professional experience in neuropsychology?

     

Estimated number of hours per year during the last 3 years providing neuropsychological services?

     

Estimated number of examinations which were primarily neuropsychological in nature that you performed/supervised during the past 3 years?


     

Note: A minimum of 3 years professional experience in neuropsychology of which 1 year may be a supervised neuropsychology internship, with a minimum of 500 hours per year during the last 3 years providing neuropsychological services, is required.




Professional development

Please list neuropsychology related workshops or continuing education you have attended (last 3 years):

Title

Sponsoring Agency

Date

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


     

     

     

     

     

     

     

     

     

     

     

     

     

     

Please list neuropsychology related lectures or classes you have presented (last 3 years):

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


     

     

     

     

     

     

     

     

     

Please list neuropsychology related conference presentations / scholarly publications (last 3 years):

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


     


Professional Association Memberships:

Fellow

Member

Affiliate

APA:







CPA:







NAN:







INS:







AAPN:







AACN





Other:      










Please answer the following questions:




  1. Have you ever been convicted of or charged with a crime (felony) in any state?

Yes/No



  1. Has any licensing board or professional ethics body ever required you to surrender your license or found you guilty of violation of any ethics code?

Yes/No



  1. Are there any complaints or charges pending against you by any licensing board or professional ethics body for violation of any ethics code?

Yes/No



  1. Have you previously submitted an application to this board? If yes, in what year?

Yes/No


If you answered yes to questions 1, 2 or 3, please enclose additional documentation in the Applicant Narrative accompanying this application.





Endorsements

Please identify three (3) supervisors or professional colleagues, at least two of whom are neuropsychologists, who can verify your training and experience. Please give the endorsement forms (available on web site) to your endorsers for completion.




Endorser 1




Name:      

Address:      

City:      

State/Zip:      

Phone:      

Email:      




Endorser 2




Name:      

Address:      

City:      

State/Zip:      

Phone:      

Email:      





Endorser 3




Name:      

Address:      

City:      

State/Zip:      

Phone:      

Email:      




Endorser 4 (optional)




Name:      

Address:      

City:      

State/Zip:      

Phone:      

Email:      


Note: Candidates are encouraged to discuss any questions regarding specific requirements with the Applications Coordinator prior to submitting their application. Contact information may be found at http://abn-board.com/about-us-and-faqs/board-of-directors/.

Application Checklist:



Have you enclosed the following?

A narrative description of your neuropsychological training and work experiences, covering items that have been identified in the preceding pages. Be sure to describe the duration and nature of your work with your endorsers.


A copy of current curriculum vitae, or insert sheet documenting the dates, settings, and extent of the training, supervision, and clinical experiences described in your application, and summarizing your professional contributions such as major publications, special research projects, and other professional qualifications not covered in the application form. Include offices and positions held in local, state, regional or national organizations.
A copy of current state licenses/certificates; any Board Certifications or ASPPB CPQ if applicable
A copy of certificates of completion from predoctoral internship and postdoctoral training programs.
Have you arranged to have the following forwarded directly to the ABN Application coordinator?
Doctoral degree program and/or neuropsychology recertification program transcripts.
Internship Guidelines Verification, completed by predoctoral internship supervisor, if applicable.
Post Doctoral Training Verification completed by post doctoral supervisor(s) , if applicable.


Endorsement forms from 3 endorsers, at least two of whom are neuropsychologists.

Have you submitted application fees online?

http://abn-board.com/becoming-a-diplomate/pay-dues-or-application-fees/

Attestation

I hereby make voluntary application to the American Board of Professional Neuropsychology for

professional examination in the specialty of Neuropsychology subject to and in accordance with the rules and regulations of the Board upon successful completion of the examination process and the issuance of the diploma. I agree to be bound by the ethics of professional psychology, not only as currently endorsed by the profession, by also by the standards of practice which shall be adopted from time to time by the American Psychological Association. I agree to be bound by the Bylaws of the Board insofar as they are applicable to me either as a candidate for the diploma or as a Diplomate of this Board. I agree to disqualification from examination or from the issuance of a diploma and to forfeiture and redelivery of such diploma in the event that any of the rules governing examination and issuance are violated by me or for any of the causes set forth in the Bylaws of the Board.

I understand that the program of the Board is entirely voluntary, and I agree to make no claim against the Board, its members, or its agents, for failure to issue to me its diploma or for any action taken in connection with the application. I authorize, whenever it may be deemed appropriate by the Board, the exchange of information concerning my candidacy (before or at any time after action is taken on my application) with the American Psychological Association, with state psychological associations, with state licensing or certifying authorities, and endorsers. I authorize the Board, its members, or its agents to make, on my behalf, investigation as to my character and as to my professional standing as a representative of psychology in the community, and I authorize and invite anyone inquired of for this purpose to respond freely and to report fully and frankly to the Board any matter (without responsibility for the truth thereof) which may seem to them relevant. I waive any claim to examine such data or other information related to the examination process.

Signature: _____________________________________________

Name:       Date:      

Revised 08/16/2014 RHR





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