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Supervised Training Form

The following information identifies you (the applicant) to the institution where supervised training/practica experience
in psychology was received (Supervised Training/Practica is experience obtained as part of your formal training
that you are granted academic credit for, but is administered by an institution/organization separate but
approved by the academic institution providing your diploma/degree ). This form will automatically populate with
your identifying and contact information. Ensure this information is correct then sign, date, and send this form to the
Institution that provided your supervised training, who will then complete the form and mail it directly to ICD. Please
note: Depending on the jurisdiction, additional information may be required by the regulatory body that you apply to
after completion of the CE: ACPRO program if individual bylaws / policies require.

Part A: Personal Information

ID Number: CT-00294815 Order Number: APP-00175935
First/Given Name: Sadia Date of Birth: 04-15-1988
Middle Name: Phone Number: +923485671788
Last/Family Name: Mustafa Email Address: [email protected]

Name used when attending this supervised training experience: Sadia Mustafa

Mailing Address of Applicant:

Address 1: 128 A Khyber Block Allama Iqbal Town Lahore
Address 2:
Address 3:
City/Town: Lahore
Province/State/Territory: Punjab
Postal Code/Zip Code: 54000
Country: Pakistan

Name of Organization Where supervised training was attended: Civil District Headquarter Hospital Faislabad

I, Sadia Mustafa, hereby give my consent to to provide the information requested in PART B of this form related to my
supervised training experience, and to send this completed form directly to ICD at the following address:

For Standard and Courier:

International Consultants of Delaware
3600 Market Street, Suite 450
Philadelphia, PA 19104-2651 USA

Applicant Signature: ______________________________________________ Date Signed__________________________________________

If you have any questions, please contact ICD via phone at +1 (215) 243-5858 or use the Support option in your
ICD Applicant Portal

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Sadia Mustafa, Civil District Headquarter Hospital Faislabad
APP-00175935
EDU-00235311, Page 1
 Part B: Supervised Training (Practica)
To be completed by the official authority. Please provide the following information (in English) concerning the
supervised training experience of this applicant. Please spell out all names fully (no initials or abbreviations).

Do not leave any fields blank; mark questions that are not applicable as N/A.

Name of the student at time of supervised training:: ____________________________________________________________

Name of the organization/institution that offered supervised

training/practicum:______________________________________________________________

Services offered by organization/institution? ______________________________________________________________________________

Supervisor’s Name:____________________________________________ Supervisor’s Profession:________________________________

Title/Name of posistion held by student:____________________________________________________________________________

Start Date: Year ______ Month__________________________ End Date: Year: _____ Month______________________

Supervised Training/Practica Hours:

Was this supervised training experience full time or part time: Full Time Part Time

If Part Time, how many hours per week: ________________

Total Number of Contact Hours (per week): ________________

Direct Client Contact Hours (per week): _______________

Individual Supervision Hours (per week): _______________

Group Supervision Hours (per week): ________________

Duties and Responsibilities:

Description of Clients Seen (ex. Age, presenting Description of Services Provided (ex. Type of Service,
problem): area of practice):

Course Information
Course Credit: _______ Course No.: ___________ Year Taken: _________
Academic Institution: ___________________________________________________________________________

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Sadia Mustafa, Civil District Headquarter Hospital Faislabad
APP-00175935
EDU-00235311, Page 2
 Part C: Observed Skills
Please indicate whether the supervised training/ practice experience that the applicant attended at your organization
included observed behaviours in the following domains of Psychology

Domains Content Area Attribute In Evidence

(Y/N)
Interpersonal Relationship Knowledge of theories Interpersonal relationships
and empirical data on the Power relationships
professional relationship Therapeutic alliance
Interface with social psychology
Fluctuations of the therapeutic/professional relationship as a
function of intervention setting
Knowledge of self Motivation
Resources
Values
Personal biases
Factors that may influence the professional relationship (e.g.,
boundary issues)
Knowledge of others Macro-environment in which the person functions (e.g., work,
national norms)
Micro-environment (e.g., personal differences, family, gender
differences)
Assessment and Evaluation Assessment and Formulation of a referral question
Evaluation Skills Selection of assessment methods
Information collection and processing
Psychometric methods
Formulation of hypotheses and making a diagnosis when
appropriate
Report writing
Formulation of an action plan
Intervention and Intervention and Establish and maintain professional relationships with clients from
Consultation Consultation Skills all populations served
Establish and maintain appropriate interdisciplinary relationships
with colleagues
Gather information about the nature and severity of problems and
formulate hypotheses about the factors that are contributing to the
problem through qualitative and quantitative means
Select appropriate intervention methods
Analyze the information, develop a conceptual framework, and
communicate this to the client
Supervision Supervision Skills Sensitivity to power, cultural, sex, and ethnic issues
Articulation of clear learning objectives
Creating an open and participatory climate
Learning to be a good supervisee (open to supervision, well
prepared, able to use time efficiently, non-defensive, aware of
limits, etc.)
Ability to link learning approaches to specific evaluation criteria
Being able to differentiate between teaching and therapy
Integration of knowledge
Awareness of one’s own strengths and limitations as supervisor
Preparing a coherent evaluation based on precise learning objectives

PLEASE SEE NEXT PAGE

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Sadia Mustafa, Civil District Headquarter Hospital Faislabad
APP-00175935
EDU-00235311, Page 3
 Part D: Identification of Official
To be completed by the official authorized to provide supervised training information for this applicant. Please provide
the following information and spell out all names fully (no initials or abbreviations).

Official authorized to provide registration information

Printed name: _________________________________________ Official Title: ____________________________________________

Phone Number: _______________________________________ Alternate Phone Number: ____________________________________
(123-456-7890 format with country code)

Email Address: ________________________________________ Website Address: ______________________________________________

Current address of this organization:

Name:_______________________________________________________________________________________________________________________
Address 1:___________________________________________________________________________________________________________________
Address 2: __________________________________________________________________________________________________________________
P.O. Box:_____________________________________________________________________________________________________________________
City/Town:___________________________________________________________________________________________________________________
Province/State/Territory:____________________________________________________________________________________________________
Postal Code/Zip Code:______________________________________________________________________________________________________
Country:_____________________________________________________________________________________________________________________

By signing below, I certify all information is true and correct to the best of my knowledge and has been provided by has
been provided by the appropriate official.

Official’s Signature: ______________________________________ Date Signed: _____________________________________(dd/mm/yyyy)

[Official signature, date signed, and seal or stamp are required for this document to
be accepted.]

In the space to the left, place the official seal or stamp of this organization.

Please mail this completed for with any additional documents to:
Postal Mailing Address
International Consultants of Delaware
3600 Market Street, Suite 450
Philadelphia, PA 19104-2651 USA

If you have any questions, please contact ICD via phone at +1 (215) 243-5858.

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Sadia Mustafa, Civil District Headquarter Hospital Faislabad
APP-00175935
EDU-00235311, Page 4