Membership Application Form - Questionnaire

The undersigned hereby subscribes to the By-laws of CAPDA and undertakes to comply with the rules and regulations of the Association. The revised by-laws are available online and should be reviewed carefully.

Note: You will receive a copy of the submitted form to the email you provide below.

CONTACT INFORMATION (for the CAPDA directory and website)

Title (Eg: 'Dr.')

Given Name(s)

LastName

Designation

Company

Address

City

Province

select

Postal Code

Phone Number

   Ext:

Alt Phone Number

Fax Number

Email Address

Website

MEMBERSHIP INFORMATION (for internal records only)

Highest Degree Earned

Do you currently hold registration, license, or full membership as a doctoral level Psychologist with a provincial or state regulatory body?

Full Name of Regulatory Body

Date of Registration

Certificate Number

Has your practice been restricted by a provincial or state regulatory body? If your answer is yes, please explain below

Do you have a doctoral degree from an accredited educational program acceptable to your provincial or state regulatory body for registration for the practice of psychology?

Name of University

Year of Graduation

Program Name

Do you have at least five years of post-doctoral experience relevant to psychological disability assessment? (Note: applicants with less than five years of relevant post-doctoral experience and training in psychological disability assessment should instead apply to become a Candidate for Membership).

Please describe this experience below, noting the services delivered, settings, special training, client groups, supervision, etc.

In your judgment, are you a member in good standing of the profession?

If you have less than five years of relevant post-doctoral experience and training in psychology relevant to psychological disability assessment, are you pursuing further training, education experience, and practice in psychological disability assessment (e.g., this might include attending conferences and workshops, conducting disability assessment under supervision, self-directed learning/readings, peer consultation)?
If yes, please briefly describe your plans for further training, education and experience:

Please describe below your experience in disability assessment and/or rehabilitation management/treatment.

Have you documented (so that you can attest to having completed) at least 50 continuing education hours in disability assessment over the past year?
Note: peer consultation and supervisory hours (both as supervisor or supervisee), self-directed reading and research, formal workshops all count as continuing education hours

Please specify the number of hours per week you devote to disability assessment and/or rehabilitation management/treatment.

Please list the professional organizations to which you belong and your membership status.

I will have (or have had) two letters in support of my Application submitted to CAPDA by two Full Members (who are not CAPDA Directors) in good standing with CAPDA.

(If you are not known to any Members, you may have two letters of reference submitted by registered psychologists, and be interviewed by two Directors, who will act as sponsors and confirm this in writing to the Chair of the Membership Committee. If the applicant has one letter of reference from a Member, then only one Director's interview and sponsorship is required.)
Letters should be sent directly by your referees by email to admin@capda.ca

I have paid the $25.00 fee.

I have submitted or will be submitting a copy of my Professional Vitae. This is mandatory in order for your application to be considered! Your vitae can be also submitted through email to admin@capda.ca

I have submitted a sample disability assessment report (with examinee and other identifying information removed). This is mandatory in order for your application to be considered! Reports can also be submitted in PDF or Word format through emai to admin@capda.ca

Applicants for Member (but not for Candidate) are required to provide a sample disability assessment. Please consider the following in doing so.

The CAPDA website has links to sites that discuss standards for disability assessment reports.

Practice standards are addressed here: http://capda.ca/docs/my-capda/practice-standards-for-the-psychological-assessment-of-disability-and-impairment.pdf?sfvrsn=0

The Practice Handbook for MVA Work, 2010, contains a lot of helpful information re reports (esp. pages 9-19).

Also, OPA Auto Guidelines for Assessment and Treatment in Auto Insurance Claims (esp. 45-65), 2010.

Also, APA Specialty Guidelines for Forensic Psychology, especially section 10, Assessment.

The Joint OPA/CAPDA Guidelines for Best Practices in Psychological Insurer Examinations, Aug 30, 2016. http://www.capda.ca/news-and-events/news/2016/08/30/the-joint-opa-capda-guidelines-for-best-practices-in-psychological-insurer-examinations

 

In addition to the above formal references, please consider the following.

1. Ensure that the report is a disability assessment, as opposed to strictly diagnostic or a treatment report. A third party report usually lends itself best to this purpose. The report is essentially forensic, involving matters that may be contentious, such as eligibility for a disability claim, a tort, or (in the case of an Independent Medical Examination) another clinician’s application for assessment or treatment or assessing entitlement to a benefit (including accessing resources for education or provision of services for those with developmental disabilities).

2. Redact identifying information thoroughly. The examinee’s first or last name should never appear in the report. Names of spouses are redacted, as is other identifying information such as precise date of birth (though year should be kept in), and employer. If the report might be embarrassing to another clinician or any other person, that person’s name is redacted.  In addition to the body of the report, please check headers, summaries, and insurer’s questions.

3. The report needs to be neutral in tone and demonstrate good scientific reasoning ability.  Conclusions follow logically from data, including collateral reports, interview, behavioural observations, and tests or inventories. Alternative hypotheses are shown to have been considered. General validity considerations, including use of symptom validity indicators, are noted. Issues related to culture, language, and other matters of diversity are addressed. Invalid results are not assumed to imply absence of disability.

4. Typographical errors are minimized.

5. The report should be comprehensive but not over inclusive.

6. Conclusions and recommendations are limited to the assessor’s scope of practice in psychology, although considerations outside this scope of practice may be noted, deferring to the appropriate health professional.

Additional Comments

PRACTICE INFORMATION (for the CAPDA directory and website)

Assessment Services

Do you conduct disability assessments?

If YES, please answer the following questions:

What percentage of your work are disability assessments?
Check the types of disability assessments conducted:



Other (please describe):

Check the age groups for which this is provided:





Other (please describe):

Check referral sources for disability assessments:






Other (please describe):

Therapy Services

Do you provide rehabilitation-oriented therapy?

If YES, please answer the following questions:

What percentage of your work is rehabilitation-oriented therapy?

Scope of rehabilitation therapy services includes:
Types of intervention:









Other (please describe):

Types of conditions:








Other (please describe):

Check the age groups for which this is provided:





Other (please describe):

Check referral sources for rehabilitation-oriented therapy:





Other (please describe):

Languages in which you provide services






















Other (please describe):

Authorization

Would you like the above contact and practice information published on the CAPDA website and in the directory?

(By indicating “yes” you authorize CAPDA to publish the above contact and practice information on the CAPDA web site, and acknowledge that it is your responsibility to update your profile of notify the Association of any changes to your contact information)

Interest in CAPDA Committee Activities

Please indicate your interest in assisting CAPDA’s working committees and/or your interest in being a Board member.











Canadian Academy of Psychologists in Disability Assessment

312 Oakwood Court, Newmarket, Ontario   L3Y 3C8
Phone:
(905) 597-6690   FAX: (905) 895-1630
Toll Free: (844) 702-2732     (844)-70-CAPDA (844)
E-Mail: admin@capda.ca
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