Clinician Onboarding

Name *

First Name

Last Name

Gender *

Clients sometimes express a preference for a clinician of a certain gender. We make every effort to accommodate these requests in order to make our clients feel as safe and as comfortable as possible

Male

Female

Transgender

Non-binary

Other

Phone *

(###)

###

####

Please select your degree *

If other, please explain in the comments section at the end of this form.

MD

PA

PsyD

PhD in Psychology

Psychologist (MA or MS)

NP

LCSW

Other

Are you affiliated with UCLA *

At this time, only clinicians affiliated with UCLA are able to volunteer with the DGSOM Asylum Clinic. If you are not currently affiliated with UCLA, or are not sure whether or not you are, please describe your relationship with UCLA in the comments section at the end of this form and we will reach out to you to explore options for working with us.

Yes

No (please explain below)

Have you been trained to conduct forensic medical examinations of asylum seekers by PHR? *

Answer yes to this question if you attended our training on September 22, 2018 or another PHR-approved training.

Yes

No

Please indicate the date and location of your training was completed

MM

DD

YYYY

What types of evaluations are you comfortable performing? *

You may select more than one if applicable. Clinicians are not limited to performing evaluations in their speciality.

Medical evaluation for adults (including evaluation for physical sequelae of trauma and basic psychiatric evaluation)

Medical evaluation for children under age 18

Psychiatric evaluation for adults

Psychiatric evaluation for children under 18

Gynecologic evaluation

Other (please describe at the end of this form)

Would you be willing to perform an evaluation for a client in a detention center (approximately 2 hour drive from UCLA) if needed? *

While the travel makes detention evaluations a much larger time commitment than a standard evaluation, these are also some of our clients in greatest need of evaluations. Visiting a detention center can also be a unique and eye-opening experience for the evaluator and learners.

Yes

Maybe, I need more information

No

How many forensic evaluations have you completed to date? *

0

1-3

3-6

More than 6

If you are an attending physician with limited/no experience performing evaluations, would you prefer to shadow an evaluation by another experienced clinician before completing one yourself? *

Shadowing is optional for clinicians. The the alternative to shadowing an experienced physician conduct an evaluation is to work closely with them in a precepting model that involves you conducting most of the evaluation yourself.

I do not need to shadow

I could perform an evaluation on my own if I was mentored throughout the entire process by an experienced clinician (experienced clinician would not be present at eval)

I definitely want to shadow before doing an evaluation on my own (experienced clinician would be present at eval)

I would prefer to shadow but am prepared to do an evaluation on my own if needed

I am not sure, please send me more information

How many forensic evaluations would you like to complete in a year (roughly)? *

1

2-4

4-6

6+

Do you speak any languages besides English fluently? If yes, please indicate below *

Yes

No