Appendix
I. Questionnaire American Psychological Association Clinical Section Committee on Study of Clinical Psychologists and Psychological Clinics: Dr Andrew W. Brown, Institute for Juvenile Eesearch, Chicago, 111., Chairman Dr E. A. Brotemarkle, University of Pennsylvania, Philadelphia, Pa. Dr Maud A. Merrill, Stanford University, Palo Alto, California Dr Clara Harrison Town, Children’s Aid Society, Buffalo, N. Y. Psychological Clinic Questionnaire
Section I
Clinic Organization 1. Name of Clinic: 2. Address: 3. Affiliations (Connection with University, Hospital, Court, Board of Edi> cation, Social Agency, Institution, etc.): 4. Personnel of Clinic Staff: (a) Psychologists: Total Number Data re each: 1. Name, 2. Clinic title, 3. Degrees held, 4. Experience, 5. Qualified to give expert testimony, 6. Licensed in State (b) Psychiatrists: Total Number Data re each: 1. Name, 2. Clinic title, 3. Degrees held, 4. Experience (c) Physicians: Total Number Data re each: 1. Clinic title, 2. Degrees held, 3. Experience (d) Besearch Workers: Total Number Data re each: 1. Name, 2. Clinic title, 3. Degrees held, 4. Experience (e) Social Workers: Total Number Data re each: 1. Degrees held, 2. Training and experience (f) Teachers and Eecreation Workers: Total Number Data re each: 1. Title, 2. Degrees held, 3. Training and experience (g) Clerical assistants: Total Number
Section II
Clientele of Clinic 1. Number of persons studied annually 2. Age range of persons studied 3. Reasons given for request for study: Number Conduct problems Educational problems Neglect problems Placement problems Guidance problems Mental defects and abnormalities 4. From what sources are persons referred for study:
Section III
Clinical Procedure 1. Studies of Individuals: (a) How are facts concerning social history, environment and schooling obtained? (b) Are medical examinations, including neurological, psychiatric and visual, made by the Clinic Physician? (c) If not, how are they secured? (d) List of psychological tests used: 2. Teaching of Children: (a) Is diagnostic or clinical teaching done? (b) How much time is devoted to such training?
Section IV
Research 1. Research problems: 2. By whom is research supervised? 3. By whom is research conducted? 4. Time assigned for research:
Section V
Training and Practice in Clinic Service 1. Academic requirements for such training: 2. Remuneration given during training period: Amount given No remuneration 3. Types of training offered: 4. Time required of students: Full time Part time 5. Number of students accepted:
Section YI
Affiliated Educational Institution 1. Name of Institutions 2. Organisation of courses Relation to Clinic
Section VII
Past and Future of Clinic 1. What were the circumstances which led to establishment of Clinic? 2. Under what auspices was it organized, and with what other community organizations was it originally affiliated? 3. What are the main difficulties you have encountered in organizing and carrying on the Clinic? 4. What changes would you, if possible, inaugurate in the mode of organization, in the nature of affiliation, in type of problems, in makeup of staff, etc., to more fully reach the desired aims of your Clinic? PB 3375-21
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