Honorific== select == Mr. Ms. Miss Mrs. Dr.
First Name
Last Name
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Prov/State== select == ==Canada== AB BC MB NB NL NS NT NU ON PE QC SK YT ==USA== AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY ==International== Other
Country== select == Canada United States --- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
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Highest Degree Earned
Please provide provincial/state registration/license information:
Full Name of Regulatory Body
Date of Registration
Certificate Number
If your practice has been restricted by a provincial or state regulatory body, please explain below
If 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, please enter below
Name of University
Year of Graduation
Program Name
If you have at least five years of post-doctoral experience relevant to psychological disability assessment, please describe this experience below, noting the services delivered, settings, special training, client groups, supervision, etc. (Note: applicants with less than five years of relevant post-doctoral experience and training in psychological disability assessment should instead apply to become an Early Disability Assessor Member).
In your judgment, are you a member in good standing of the profession? Y N
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
Describe your experience in disability assessment and/or rehabilitation management/treatment
If you have documented (so that you can attest to having completed) at least 50 continuing education hours in disability assessment over the past year, please specify the number of hours per week you devote to disability assessment and/or rehabilitation management/treatment. Note: peer consultation and supervisory hours (both as supervisor or supervisee), self-directed reading and research, formal workshops all count as continuing education hours
List the professional organizations to which you belong and your membership status
Submit two (2) letters of reference from registered psychologists.
Application Letter 1 Your documents need to be a PDF or Word file. File size limit is 4 MB
Application Letter 2 Your documents need to be a PDF or Word file. File size limit is 4 MB
Professional Vitae - This is mandatory in order for your application to be considered! Your documents need to be a PDF or Word file. File size limit is 4 MB
Sample Disability Assessment Report - with examinee and other identifying information removed. This is mandatory in order for your application to be considered! Your documents need to be a PDF or Word file. File size limit is 4 MB
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.
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.
In addition to the above formal references, please consider the following.
Additional Comments
Bio
Locations Where Clinician is Licensed to Practice AB BC MB NB NL NS NT NU ON PE QC SK YT
If you conduct disability assessments, what percentage of your work are disability assessments?
Check the types of disability assessments conducted: Clinical Health Neuropsychology Rehabilitation Vocational Other If you select 'Other', please describe:
Check the age groups for which this is provided: Adolescents Adults Children Elderly Infants Other If you select 'Other', please describe:
Check referral sources for disability assessments: Assessment Agencies Insurers Lawyers Physicians Rehab Personnel Self Other If you select 'Other', please describe:
Types of intervention: Behavioural Biofeedback Cognitive Cognitive Retraining Family Hypnosis Insight Oriented Marital Rehabilitation Counselling Other If you select 'Other', please describe:
Types of conditions: Adjustment Disorders Anger Anxiety Disorders Behavioural Disorders Chronic Pain Cognitive Impairment Mood Disorders Post Traumatic Stress Disorder Other If you select 'Other', please describe:
Check referral sources for rehabilitation-oriented therapy: Insurers Lawyers Physicians Rehab Personnel Self Other If you select 'Other', please describe:
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Show my email on the public Member Directory Y N