PLEASE COMPLETE THE PRE-APPLICATION SCREENING FORM IN FULL

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4 PLEASE COMPLETE THE PRE-APPLICATION SCREENING FORM IN FULL 1. PERSONAL INFORMATION SURNAME.TITLE FIRST NAMES AGE GENDER.DATE OF BIRTH. STUDENT NUMBER (only applicable to UL students) MARITAL STATUS TELEPHONE NUMBER (H) (W) ADDRESS RESIDENTIAL ADDRESS POSTAL ADDRESS.. Page 4 of 11

5 2. ACADEMIC RECORD (Attach certified copies of results/symbols) 2.1 MATRICULATION: YEAR SCHOOL... SUBJECTS AND SYMBOLS: 2.2 UNIVERSITY QUALIFICATIONS (Attach certified copies and academic record) DEG/DIPLOMA INSTITUTION YEAR OF REGISTRATION YEAR OBTAINED 2.3 If you are presently enrolled for Honours, please mention the university concerned and expected date of completion 2.4 OTHER QUALIFICATIONS: 3. OTHER PROFESSIONAL OR APPROPRIATE EXPERIENCE: (Mention any other relevant experience in psychology and/or membership of association in this discipline, or experience which you consider to have been meaningful in the formation of your character). Page 5 of 11

6 4. SCHOLARSHIPS OR BURSARIES RECEIVED: 5. LANGUAGE ABILITY: LANGUAGE POOR GOOD VERY GOOD ENGLISH N. SOTHO TSHIVENDA XITSONGA AFRIKAANS Page 6 of 11

7 OTHER: SPECIFY 6. STATE OF HEALTH: 6.1 PHYSICAL WELL-BEING: Describe your present state of health and mention any physical factors that may be relevant in the evaluation of your application. 6.2 MENTAL HEALTH: Describe your present state of mental health. Mention any factors with regard to treatment, or medication that may be relevant to the evaluation of your application. 7. APPLICATIONS MADE TO UNIVERSITIES: 7.1 If you intend applying to any other university this year, mention this as well and the categories of applications. 7.2 Have you ever submitted an application to this university? If so, for which course and which year? 8. PREVIOUS CRIMINAL RECORD Do you have any previous criminal record/s? Yes/No If yes, please explain Page 7 of 11

8 REFERENCES: Please select two referees who are able to submit comments about your suitability as a candidate for the course. Each referee must complete a form and return it to the Department of Psychology. Please ensure that your referees are willing to furnish the required information and that their reference forms reach the department. NB. No lecturer in the Department of Psychology at the University of Limpopo or any family member or friend can be selected as a referee. 1.1 Title, Initials & Surname:... Capacity:... Address:... Postal Code:... Tel No: Fax No: Title, Initials & Surname:... Capacity:... Address: Postal Code:... Tel No: Fax No: I hereby declare that the information provided in the pre-application screening form is correct, and that no information has been purposely withheld SIGNATURE DATE Page 8 of 11

9 Name of candidate The above mentioned candidate nominated you as a referee in an application for admission to a Master s Degree in Clinical Psychology. Kindly respond to the following questions and send the report at your earliest convenience to the following address on or before the 20 July 2018: hellen.phoshoko@ul.ac.za 1. In what capacity have you known the applicant and for how long? In your opinion, how suitable is the candidate for this type of training? What do you consider to be the candidate's strongest qualities? What do you consider to be the candidate's major limitations?... Page 9 of 11

10 Please rate the candidate on the following items as indicated in the table hereunder: Below Average Average Good Excellent Unable to judge 5. Intellectual ability 6. Research ability 7. Writing skills 8. Motivation 9. Resourcefulness and initiative 10. Perseverance 11. Adapting to new situations 12. Personal maturity 13. Co-operativeness 14. Openness to new ideas 15. Openness to critical feedback 16. Insight into own personality 17. Empathy 18. Interpersonal skills 19. What reservation might you have about the candidate training to become a clinical psychologist? Please provide any additional information that would help evaluate the candidate.... Page 10 of 11

11 Name of referee:... Title:... Position/Profession:... Address:... Tel. Number: Signature Date Thank you for your co-operation. Page 11 of 11