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Qualifications Office

Qualification in Clinical NeuropsychologyUseful Forms and Case Log Book Examples

From September 2018

Qualifications Office

The British Psychological Society,St Andrews House,

48 Princess Road East,Leicester, LE1 7DR.

Tel: (0116) 252 9505Fax: (0116) 227 1314

Email: [email protected]

http://www.bps.org.uk/qualifications

Contents

Page

Checklist for enrolment 4Enrolment Form 5Request for Approval of Supervisor 9Plan of Training 10Supervision Plan 12Application for Exemption Form 16Supervision Log 18Clinical Log Book Summary Sheet 19Case Log Book Example – blank 20Case Log Book Example 1 – Adult 21Case Log Book Example 2 – Adult 22Case Log Book Example 3 – Paediatric 23Case Log Book Example 4 – Paediatric 25

Important Note

Candidates are reminded that they should make every effort to ensure that all documentation including their supervision plan is word processed and accurate. The most common source of delays in processing applications to enrol for the Qualification in Clinical Neuropsychology arise as a result of forms which are incomplete or contain inadequate information.

CLINICAL NEUROPSYCHOLOGY QUALIFICATIONS BOARD

Checklist for Enrolment

The first stage in enrolling on the Qualification in Clinical Neuropsychology is to identify a clinical supervisor who is a Full Member of the DoN and who appears on the Society’s Specialist Register of Clinical Neuropsychologists.

The next stage is to send the following to the Society’s Leicester Office:

Enrolment form

Plan of Training form

Supervision Plan

Request for approval of supervisor form (if your supervisor has not previously been approved as a clinical supervisor for the QiCN)

A copy of the contract(s) agreed and signed by you and your supervisor(s) (for all supervisors named on your supervision plan)

Enrolment fee (or invoice details)

Backdating fee (if applicable)

Equal opportunities monitoring form

Copy of a current certificate from either the Criminal Records Bureau, Disclosure Scotland or Access Northern Ireland (dated in the last two years or from your current post)

Application for exemption form and supporting evidence if you are applying for any exemptions

If any of this information is missing your application will not be processed. Please read the Candidate Handbook and the Regulations for the Society’s Postgraduate Qualifications and discuss your application with your supervisor(s) before submitting it to the Society.

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Enrolment Form for the Qualification in Clinical Neuropsychology

Title: Mr/ Mrs/ Ms/ Dr Forename(s):

Surname: Date of birth:

Email:

Daytime telephone number:

Society membership number:

HCPC registration number:

To be eligible to enrol for the QiCN (adult) you must have all of the following:

Graduate Basis for Chartered Membership Yes/No

Eligibility for Full Membership of the Division of Clinical Psychology Yes/No

Registration with the HCPC as a Clinical Psychologist Yes/No

To be eligible to enrol for the QiCN (paediatric) you must have all of the following:

Graduate Basis for Chartered Membership Yes/No

Eligibility for Full Membership of the Division of Clinical Psychology or Division of Educational and Child Psychology Yes/No Registration with the HCPC as a Clinical Psychologist or an Educational Psychologist Yes/No

Do you wish to apply for exemption from any part?

Part 1: Underpinning knowledge Yes/No

Part 2: Research Portfolio Yes/No Part 3: Portfolio of Clinical Competence Yes/No

If you wish to apply for any exemptions, complete and return the Application for Exemption Form with this enrolment form

Please give details of your proposed (Principal) Clinical Supervisor:

Name...................................................................................................................................................

Membership No.......................................HCPC registration number..................................................

Please give details of your proposed Research Supervisor unless applying for an exemption:

Name...................................................................................................................................................

Membership No.......................................HCPC registration number..................................................

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Enrolment Form for the Qualification in Clinical Neuropsychology (continued)

Previous enrolment for a Society-accredited training programmeHave you previously been enrolled for a Society-accredited training programme and left prior to completion? Yes/No

If yes, please state why you left the programme:

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

For details of the current fee for the Qualification in Clinical Neuropsychology please refer to qualification webpage. The fee can be paid either in a lump sum via BACS or card or by monthly interest free direct debit spread between one and four years. Please indicate below which payment option you wish to choose:

Payment in full by BACS transfer Please contact the Qualifications Office for the account details.

Payment in full by card Please telephone 0116 252 9505 to arrange payment.

Payment via monthly direct debit I wish to pay this over _____ months

Please complete the direct debit mandate available online and clearly state the period over which you wish to pay the fee.

Payment in full by a third party Please provide invoicing details below.

If payment is being arranged in full via a third party:

Please provide the full name and address for the invoice along with a purchase order number, if your employer uses the purchase order system:

Name:

Postal Address:

E-mail Address:

Purchase order number (if applicable):

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Disability Discrimination ActIf you have a disability or special requirements you may need the Society to make reasonable adjustments to, or provide special facilities for, your examination. If this is the case please advise us here.

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We will contact you to discuss your requirements and to ensure that adequate arrangements are made.

References

Please include two references with your enrolment application. The reference form can be found on the qualifications webpage.

One reference must relate to your academic studies and the other reference must relate to your practice. At least one name must appear on the Society’s Register of Chartered Psychologists and the psychology section of the Health and Care Professions Council’s Register. Your Co-ordinating Supervisor (as named on your supervision plan) and fellow candidates cannot normally be named as referee.

Candidate’s Declaration

I wish to be enrolled on the British Psychological Society Qualification in Clinical Neuropsychology, and confirm that I have read the current Candidate Handbook for the Qualification in Clinical Neuropsychology and that I will maintain an updated knowledge of the Candidate Handbook. I certify that I have the Graduate Basis for Chartered Membership with the British Psychological Society and am currently registered with the Health and Care Professions Council as a Clinical Psychologist/Educational Psychologist (delete as appropriate) and that the facts stated on this form are correct:

Signature of Candidate: Date:

Agreement of Co-ordinating Supervisor

I confirm that I have reviewed this application and discussed it with the above named applicant. I confirm my agreement to act as Co-ordinating Supervisor for this applicant. I am a full member of the Division of Neuropsychology and am named on the Society’s Specialist Register of Clinical Neuropsychologists. I am entered on the Register of Applied Psychology Practice Supervisors, or am willing to undertake training to meet this requirement. I agree to be responsible to the Clinical Neuropsychology Qualifications Board for the items listed in the Candidate Handbook for the Qualification in Clinical Neuropsychology as the responsibilities of the supervisor. I will undertake training for the role of QiCN supervisor within 12 months of approval if required.

Signature of Co-ordinating Supervisor:

Date:

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This form should be returned to:Qualifications Office

The British Psychological SocietySt Andrews House

48 Princess Road EastLeicester LE1 7DR

By providing the personal information in the application form you are agreeing to the Society processing and holding it only for the purposes stated in our Data Protection Act registration. For further information about these purposes and the Act itself please visit the privacy\DPA policy hyperlink at the foot of the Society’s website home page at www.bps.org.uk

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http://www.bps.org.uk/


Request for Approval of Proposed Supervisor for the Qualification in Clinical Neuropsychology

Proposed supervisor’s name:...........................................……………………………………………………

Proposed supervisor’s membership number:............................................…………………………………

Proposed supervisor’s HCPC registration number:...................................…………………………………

Proposed supervisor’s phone:..........................................……………………………………………………

Proposed supervisor’s e-mail:..........................................……………………………………………………

Is the proposed supervisora Full Member of the Division of Neuropsychology and entered on the Specialist Register of Clinical Neuropsychologists:.....................................................................................................................Yes/No

Name of Candidate who proposes to be supervised: .............................................................................

Candidate’s membership number: ..........................................................................................................

Candidate’s HCPC registration number:..................................................................................................

Date when supervision plan naming proposed supervisor was / will be submitted: ...............................

.................................................................................................................................................................

Please attach a brief CV regarding the proposed supervisor. This must include details of their current post.

Newly approved supervisors for the QiCN will need to undertake training for the role normally within 12 months of being approved in the role.

Proposed supervisor’s signature: .......................................................................................................

Date:....................................................................................................................................................

Candidate’s signature:.........................................................................................................................

Date:....................................................................................................................................................

Return this form to:

The Qualifications Administrator for the QiCNThe British Psychological Society

St Andrews House48 Princess Road East

Leicester, LE1 7DR

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Plan of Training for the Qualification in Clinical Neuropsychology

1. Candidates Details:

Name: .............................................................................................................................................

Membership number: .......................................................................................................................

HCPC registration number:...............................................................................................................

Telephone Number: ..........................................................................................................................

Email: ..............................................................................................................................................

2. Planning to undertake (Tick one): Adult QiCNPaediatric QiCN

3. Date gained registration with the HCPC as a Clinical Psychologist:........................................

Date gained eligibility for Full Membership of the Division of Clinical Psychology:...............

(or for some candidates for Paediatric QiCN),

Date gained registration with the HCPC as an Educational Psychologist:...............................

Date gained eligibility for Full Membership of the Division of Educational and Child Psychology:....................................................................................................................................

4. Method by which you plan to complete the Knowledge Dimension (Part 1):

by completing a Society accredited university course at

……………………………………………… (name of university)

by taking the examinations and essays set by the Clinical Neuropsychology Qualifications Board

by applying for exemption on the basis of a Society-accredited course already completed

at ………………………………….. (name of university) (complete separate Exemption Form).

5. Method by which you plan to complete the Research Dimension (Part 2):

by completing the research component of a Society accredited MSc course in clinical

neuropsychology at ………………………….…………(name of university)

by undertaking a piece of research and submitting a research portfolio for assessment by the Clinical Neuropsychology Qualifications Board

by applying for exemption on the basis of a research project that was examined

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as part of a post-graduate qualification or published in a peer-reviewed journal (complete separate Exemption Form)

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6. Method by which you plan to complete the Practice Dimension (Part 3):

by completion of 2 years full-time clinical neuropsychology practice

by completion of part-time clinical neuropsychology practice, working

……………of whole-time, so taking …………. months to achieve equivalent

of 24 months full-time.

With supervision from: ……………………………………………….. (name)

and ………………………………………………….(name)

(if another supervisor will contribute).

(Also complete a separate Clinical Supervision Plan.)

Candidate’s signature:......................................................................................................................

Date:....................................................................................................................................................

Co-ordinating Supervisor’s signature:............................................................................................

Date:....................................................................................................................................................

Return this form to:

The Qualifications Administrator for the QiCNThe British Psychological Society

St Andrews House48 Princess Road East

Leicester, LE1 7DR

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Supervision Plan for the Qualification in Clinical Neuropsychology

Guidance notes for completion of the supervision plan

If you are requesting backdating of clinical practice, you must ensure that the supervision arrangements outlined in your supervision plan cover both the proposed backdated period and the forward period of practice. This includes the names of your supervisors and frequency and duration of supervision.

If you are requesting backdating of clinical practice, the proposed start date of your supervision plan will be retrospective. You must make clear the period which you want to be backdated. The maximum period of backdating that can be granted is 12 months (or part time equivalent).

You must ensure that you have clearly indicated that you have plans in place to accrue a minimum of 60 hours of supervision during the course of your supervision plan. Please check that the frequency and duration of supervision which you stipulate in your plan amount to the required 60 hours. If they do not amount to at least 60 hours, please do not submit your application to enrol until you have concrete plans for some additional supervision. This is one of the most common reason for delays in processing an enrolment application.

Candidates are reminded that they should make every effort to ensure that all documentation including their supervision plan is word processed and accurate. Alterations/additions will only be considered in exceptional circumstances after a written submission to the Qualifications Administrator has been discussed with the Registrar and Chief Supervisor.

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Supervision Plan for the Qualification in Clinical Neuropsychology

1. Candidate's details

Candidate’s name:....................................................................................................................

BPS Membership No:............................HCPC registration number:.......................................

Telephone Number (work):...........................................Fax:.....................................................

Email: .......................................................................................................................................

Details of current employing organisation:................................................................................

..................................................................................................................................................

..................................................................................................................................................

2. Proposed Co-ordinating Supervisor's details

Name of proposed Co-ordinating Supervisor:..........................................................................


Position held:............................................................................................................................

Email: .......................................................................................................................................

Is this supervisor located within the candidate’s service?........................................................

Please give a brief description of this supervisor's current employing organisation and responsibilities.

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

Is this supervisor a Full Member of the Division of Neuropsychology and entered on the Society’s Specialist Register of Clinical Neuropsychologists? Yes/No

Has this supervisor already been approved by the Clinical Neuropsychology Qualifications Board? Yes/No

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3. Supervision Plan

Date when supervised clinical practice is expected to start .....................................................

Date when supervised clinical practice is expected to be completed ......................................

If you are applying for backdating by putting a retrospective start date above, please confirm that you have been keeping a case log and supervision log for the backdating period (please do not submit these, but retain them and insert them into your portfolio for assessment at the appropriate point):

..................................................................................................................................................

..................................................................................................................................................

Will the proposed Co-ordinating Supervisor be able to provide supervision for the full range of clinical work needed for the clinical portfolio (to include acquired and non-acquired brain injury, degenerative conditions, psychosomatic disorder, a range of disability and a range or reasons for referral)? Yes/No

Will an additional supervisor provide some of the supervision? Yes/No

If ‘Yes’, please give details of the additional supervisor:

Name of proposed additional supervisor:.................................................................................


Position held:............................................................................................................................

Email: .......................................................................................................................................

Is this supervisor located within the candidate’s service?........................................................

Please give a brief description of this supervisor's current employing organisation and responsibilities.

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

Areas of work for which additional supervisor will provide supervision:

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

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Outline the way in which supervision will be provided, giving details of where, when and how supervision will take place, and the nature and extent of supervision which will be provided. The frequency and duration of supervision stated below must ensure that 60 hours of supervision will be achieved in total. If you are receiving any group supervision, the supervisor leading this group needs to be named on this supervision plan. Supervision hours received as part of a group are calculated proportionately so please ensure that you take this into account when calculating your supervision hours.

For the Co-ordinating Supervisor

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

For additional supervisor

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

..................................................................................................................................................

Signature of candidate:.............................................................................................................

Date:.........................................................................................................................................

Signature of Co-ordinating Supervisor:.....................................................................................

Date:.........................................................................................................................................

Signature of additional supervisor:...........................................................................................

Date:.........................................................................................................................................

To be completed by the Chief Supervisor for Qualifications Board

Comments

..................................................................................................................................................

..................................................................................................................................................

Date of ratification....................................Expected date of completion..................................

Signature..................................................................................................................................16


Application for Exemption Form

Candidates for the Qualification in Clinical Neuropsychology may apply for exemption from one or more parts of the qualification. Please attach extra sheets if necessary. N.B. Applications for exemption can only be submitted at the same time as, or after, a candidate has applied to enrol on the QiCN.

Please complete the relevant section of this form for each part from which you wish to apply for an exemption

Candidate name..................................................................................................................................

Membership Number..........................................................................................................................

HCPC Registration number................................................................................................................

Telephone Number..............................................................................................................................

Email....................................................................................................................................................

I am applying for exemption from part(s) of the adult route Yes/No I am applying for exemption from part(s) of the paediatric route Yes/No

PART 1: Knowledge Dimension

A qualification in Clinical Neuropsychology or Paediatric Clinical Neuropsychology which is accredited by the Society on the recommendation of the Committee on Training in Clinical Neuropsychology will give exemption from the examination of underpinning knowledge.

Do you wish to apply for exemption from Part 1? YES/NO

Please enclose the original of either the certificate or letter of successful completion as evidence. This will be returned promptly by recorded delivery.

N.B If you are in the process of completing an accredited course in fulfilment of the knowledge dimension, please do not indicate “yes” above; please indicate on your plan of training that you are completing an accredited course and apply for exemption when you have received either the certificate or letter of successful completion.

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PART 2: Research Dimension

Research (carried out and) successfully completed as part of a Society-accredited course in clinical neuropsychology or paediatric clinical neuropsychology will give exemption from the research portfolio requirementOrResearch in clinical or educational psychology as part of a postgraduate qualificationOrResearch published in good quality peer reviewed journals

Do you wish to apply for exemption from Part 2? YES/NO

Please indicate the evidence that you are providing for this exemption:

1. Original certificate or letter of successful completion from a Society-accredited Masters degree in Clinical Neuropsychology or Paediatric Clinical Neuropsychology; YES/NO

2. An abstract of a piece of research completed as part of a postgraduate qualification in clinical or educational psychology (e.g. DClinPsy, DEdPsy), along with the original degree certificate indicating when and where the thesis was examined and the degree awarded. YES/NO

If you are applying for exemption under option 3, please provide further details below:

a. Name of university where the postgraduate qualification (e.g. DClinPsy) was completed:

............................................................................................................................................

b. Name of Qualification:

............................................................................................................................................

c. Year awarded:

............................................................................................................................................

I confirm that the enclosed abstract pertains to the above-named qualification:

Signature:.................................................................................................................................................

Name:.......................................................................................................................................................

Date:.........................................................................................................................................................

By providing the personal information in the application form you are agreeing to the Society processing and holding it only for the purpose stated in our Data Protection Act registration. For further information about these purposes and the Act itself please visit the privacy\DPA policy hyperlink at the foot of the Society’s website home page at www.bps.org.uk

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Supervision Log

This document needs to log the supervision received during the course of your supervision plan. It will need to cover a minimum of 60 hours of supervision as per the Candidate Handbook (February 2016). At least half of this supervision needs to be face-to-face and individual, and any group supervision needs to be calculated proportionately. The supervision detailed below needs to be in line with the details approved in your supervision plan. Please duplicate this page if you need to.

Candidate name:............................................................................................................................

Membership number:......................................................................................................................

Date of supervision session

Duration Method (e.g. individual, group including the size of the group, face-to-face, telephone)

Supervisor’s name Candidate’s signature Supervisor’s signature

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Clinical Log Book Summary Sheet for Qualification in working with Adults or Children and Adolescents

Case No.

Sex Age Diagnosis Assessment, intervention

or both

Hours of contact with:

client/ child

family/ carers

other prof.

Continue on a further sheet if needed

Indicate which profession contact with other prof. involved, using abbreviations such as

edn. = school/college staff, s.w. - social work, emp. = employer or employment service

Provide a key for all abbreviations used.

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Case Log Book Example - for qualifications in working with adults or children

There should be a series of sheets indicating clinical activity and signed by both candidate and supervisor

Case number:- Age:- Sex:- In/out/day patient?Seen as part of team? (Specify type of team)Date(s) seen, or period seen overSource of referralReason for referral

Diagnosis/Diagnoses : 123

Type of neuropsychology involvement (e.g., screening assessment, assessment to aid diagnosis, rehabilitation) - list all

Main neuropsychological/psychological problem(s) identified.

Assessments used (list tests, brief summary of any other types of assessment)

Clinical ActivityFace-to face contacts (number and total time)Contacts with family or carers/friends (number, relationship and time)Contacts with other professions (nature, extent and time)Other activity (nature and extent)

Outcome/outputs

The above record accurately reflects the candidate's work with this client.

Signed and dated ……………………………………………………….. (candidate)

Signed and dated ……………………………………………………….. (supervisor)

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Case Log Book Example 1- for Adult Qualification

Specimen completed in italics


Case number:- 01 Age:- 18 Sex:- M In/out/day patient? I.p.Seen as part of team? (Specify type of team) Yes - in-patient rehab. teamDate(s) seen, or period seen over Mar 01 - Oct 01Source of referral Consultant in Rehab. MedicineReason for referral For assessment and intervention as

part of in-patient rehabDiagnosis/Diagnoses : 1 Traumatic Brain Injury

2 History of anxiety and school refusal3


Assessment and intervention


Cognitive impairment - reduced speed of processing, visual perceptual problems. Behavioural problems - destructive and impulsive


WAIS - III, RBMT, FAS, TMT, NART behavioural assessment - ABC

Clinical ActivityFace-to face contacts (number and total time)

25 sessions with client - total 20 hours

Contacts with family or carers/friends (number, relationship and time)

5 face-to face with parents - 5 hours 20 telephone contacts with parents - 5 hours

Contacts with other professions (nature, extent and time)

1 face-to face with college tutor - 1 hour2 telephone contact with college - 1 hour

Other activity (nature and extent) Collaboration with nursing staff on behavioural intervention - 20 hours

Outcome/outputs Discharged home to parents, with ongoing community support




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Case Log Book Example 2- for Adult Qualification



Case number:-02 Age:-42 Sex:- F In/out/day patient? Out-ptSeen as part of team? (Specify type of team) noDate(s) seen, or period seen over 4 & 14 December 2000, 5 July 2001Source of referral Consultant NeurologistReason for referral Attention/concentration problems

following recovery from meningitisDiagnosis/Diagnoses : 1 Past meningitis

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Assessment, advice, reassessment after 6 months


Impaired attention, specific visual perceptual problems


AMIPB, VOSP, TEA


3 - total 3 hours


none

Contacts with other professions (nature, extent and time)

none

Other activity (nature and extent) Advice on return to work and driving

Outcome/outputs Subtle deficits identified, advice given, patient returned to work




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Clinical Log Book Example 3- for Paediatric Qualification



Case number:- 1 Age:- 8 Sex:- M In/out/day patient? I & D Seen as part of team? (Specify type of team) Yes – in & day patient rehab. teamsDate(s) seen, or period seen over Mar 01 –June 01Source of referral Consultant Paediatric NeurosurgeonReason for referral For assessment and intervention

Diagnosis/Diagnoses : 1 Traumatic Brain Injury23


Psychometric assessment to delineate cognitive profile and monitor progress, assessment of behaviour, assessment of psychological state of child and family. Intervention with child, consultancy to hospital team members, local education and health professionals and co-working with SALT, hospital teachers and Ed Psych.


Cognitive impairment - reduced speed of processing, language, reading and spelling problems, poor verbal memory, fatigue. Low mood, avoiding contact with peers, unable to cope in classroom. Low mood and anxiety in family members.


WISC - III, WORD, WOLD, CMS, FAS, TEA-Ch, behavioural – ABC, clinical assessment of mood & RIES & BDS




12 face-to face with parents - 8 hrs. 5 telephone contacts with parents - 3 hrs. 3 face-to-face with siblings-4hrs

Contacts with other professions (nature and extent)

1 face-to face with class teacher and SENCO - 1 hr; 3 telephone contacts with school- 1 ½ hrs. 2 face-to-face with Ed Psych-2 hrs 4 joint sessions with hospital teachers-3 hrs; 3 joint sessions with SALT 3 hrs & 2 face-to-face 1½ hrs.; 1 face-to face with hospital social worker-I ½ hrs; 1telephone contact with local Clin Psych- ¾ hr

Other activity (nature and extent) Weekly ward review with Hospital team Discharge Case Conference with hospital team and local health & education services and family. Initial and review meetings at local school. Advice provided for statementing procedure.

Outcome/outputs Discharged home to parents, with ongoing community support and review Case Conference arranged for-Autumn.


Signed and dated ……………………………………………………….. (candidate)24


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Clinical Log Book Example 4 - for Paediatric Qualification



Case number:- 2 Age:- 15 Sex:- F In/out/day patient? O Seen as part of team? (Specify type of team) NoDate(s) seen, or period seen over Jan 01 –Nov01Source of referral GPReason for referral For assessment and advice

Diagnosis/Diagnoses : 1 CVA23


Psychometric assessment to delineate cognitive profile, assessment of psychological state of child and family. Intervention (education re CVA) with child, consultancy to, local education and health professionals. Advice to family.


Cognitive impairment - reduced speed of processing, reading and writing problems, poor attention, visual memory & visuo-motor skills, fatigue. Anxiety in all family members.


WISC - III, WORD, WOLD, CMS, NEPSY, clinical assessment of mood & Ch IES, SCAS & BDS




5 face-to face with parents & sibs - 6 hrs. 3 telephone contacts with family –1hr

Contacts with other professions (nature and extent)

1 face-to face with class teacher 1 hr, 1 telephone contacts with school- ½ hr.1 face-to-face with Ed Psych 1 hr 2 telephone contacts-1 hr.

Other activity (nature and extent) Case Conference with local health & education services and family. Advice provided for assessment of special needs.

Outcome/outputs Discharged. Review by Ed Psych.




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€¦ · web viewdiagnosis/diagnoses : 1 traumatic brain injury 2 3 type of neuropsychology...

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