Rehabilitation Council of India

(A Statutory Body under the Ministry of Social Justice and Empowerment)

Examination for Certifying Clinical Competency (EC3)

Application for Part I (Preliminary)
Center Preference:

Chennai

New Delhi

Kolkata

Mumbai

Affixrecent
passportsize
photograph4.5cm
X3.5cm

DD No., date, bank & amount: _______________________________________

_________________________________________________________________
1.0 Personal Information
Applicants Name (Block letters): ___________________________________________________
_____________________________________________________________________________

Date of Birth: _____________________________,

Sex: __________

Postal address for communication: _________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Contact details Phone: __________________________________________________________

Email: ________________________________________________________________________

2.0 Academic Qualification

2.1 Bachelor Degree:
Title __________________

Annual

Semester

College: _______________________________________________, University: _____________

Month and Year of passing: _____________________

Subjects Studied in Bachelor Degree (Enclose attested copy of the Degree Certificate and
Statement of Marks):
Year I: ______________________________________________________________________
______________________________________________________________________________

Year II: _____________________________________________________________________

______________________________________________________________________________

Year III: _____________________________________________________________________

______________________________________________________________________________

2.2 Masters Degree:

Title__________________, In _____________________________________ (specify the branch
of Psychology, such as Applied, Clinical, Counseling etc.)
Annual or

Semester

Regular or

Distance mode

College: ________________________________________, University: ____________________

Month and Year of passing: ______________________

Subjects Studied in Masters Degree (Enclose attested copy of the Degree Certificate and
Statement of Marks):
Year I: _____________________________________________________________________
_____________________________________________________________________________

Year II: _____________________________________________________________________

______________________________________________________________________________

Aggregate Percentage (or Grade) in Masters Degree:___________________________________

2.3 M.Phil Rehabilitation Psychology:

Month and Year of Passing (Enclose attested copy of the Degree Certificate and Statement of
Marks): ___________________________________
CRR No.: _____________________________
Name of the Center from where the Degree was obtained: _______________________

Name of the University: __________________________________________________________

List of RCI recognized courses conducted at the Center: ________________________________

______________________________________________________________________________

2.4 Ph.D. Degree:

Discipline:_____________________________________________________________________

Title of the Doctoral dissertation: __________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Name & Address of the Guide: ____________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

CRR No. of the Guide: ___________________________________________________________

Name of the RCI recognized Center from where Degree was obtained: ____________________
_____________________________________________________________________________
Name of the University: _________________________________________________________

List of RCI recognized courses conducted at the Center: ________________________________

_____________________________________________________________________________

Month and Year of Registration: _________________, Month and Year of Award: ___________
(Enclose attested copy of the Degree Certificate)

3.0 Overseas Qualification:

Are you holding a valid License to practice Clinical Psychology outside India?

Yes

No

What professional qualification has led to your licensing?_______________________________

(Attach details of your professional qualification and attested copies of degree certificate, grade
sheet, training certificate and the license.)

Year of Licensing:___________________________, Renewal Date:_______________________

Licensing Authority: ____________________________________________________________

4.0 Practicum Experience Following Masters degree Program

(If you have gained required hours of practical experience at more than one Center, mention
here details of the Center where you gained maximum experience and attach details for each
of the Center separately following the same headings.)
Name of the Center (Psychological service setting) where you gained practical experience:
_____________________________________________________________________________

Nature of professional activities/services carried out at the Center (attach list):

_____________________________________________________________________________
_____________________________________________________________________________

Training/courses offered at the Center (attach list):

_____________________________________________________________________________
_____________________________________________________________________________

Registered Clinical Psychologist/s at the Center with their qualification, experience and their
CRR number (attach details):
_____________________________________________________________________________
_____________________________________________________________________________

Other mental health professionals at the center with their qualification, experience and their
Registration Number (attach details):
______________________________________________________________________________
______________________________________________________________________________

Year of establishment of the Center: ________________________________________________

Number of beneficiaries per week at the Center: _______________________________________

Date of your Joining the Center: ________________________, Date of Exit:________________

Is your work supervised by Registered Clinical Psychologist?

If yes, is the supervision fulltime?

Yes

Yes

No

No

Name of the Supervisor:__________________________________________________________

Supervisors Qualification:________________________________________________________

Supervisors Designation:_________________________________________________________

Supervisors CRR No.: __________________________________________________________

Number of hours of practice (Post-Masters) per week under supervision: ___________________

Number of hours of practice (Post-Masters) per week independently: ______________________

Total number of practice hours (Supervised + Independent) accumulated as on December 31,

2011 ___________________

Clinical task/s performed by you at the Center (attach details):____________________________

______________________________________________________________________________

Specialty Area:

Clinical

School

Counseling

Other: _________________

5.0 Self-assessment
Describe (250-300 words) what understanding and skill you have gained from your practical
experience of working with mentally ill and how these help you in performing tasks/duties
within the field of Clinical Psychology. Also, rate your current competency level to function as
an independent professional clinical psychologist on a scale of 0 10. (Attach separate sheet).
6.0 Certificate of Experience
Attach a certificate of experience from Head of the Center attesting your practicum hours under
direct supervision of a RCI registered Clinical Psychologist who is functioning at the Center as
in-charge professional for the overall training and experience in the field of Clinical Psychology.
If you have gained the required practicum experience independently, submit a self-declaration to
this effect stating the duration, nature, breadth and depth of your independent professional
experience, and professional accomplishments since your practice.

Declaration
I, the undersigned, declare that the statements and information contained herein are true,
complete, and accurate to the best of my knowledge and belief, and that I have not intentionally
withheld or furnished any information which might influence my eligibility to appear in the
examination.

_________________________________

______________________________

Name of Applicant

Applicants Signature

Date:
Place:

Certificates & Documentation required along with application for Part I exam
1. Copy of statement of marks/grade sheet and all degree certificates
2. Certificate of experience by Head of the Center attesting the applicants Post-Masters
practicum experience (minimum 3 years of practicum experience as on December 31,
2011, amounting to at least 4000 hr. of practice learning in clinical areas under the
supervision of RCI Registered Clinical Psychologist) highlighting the breadth and depth
of professional experiences, personal qualities and accomplishments of the applicant in
the last 3 years.
3. Age proof
4. Copy of the active license in case of overseas candidate
5. Self-assessment
6. "DD for Rs.1000/- drawn in favour of "Member Secretary, Rehabilitation Council of
India", payable at New Delhi",