Application for Psychoanalytic Training

     
DATE _______________________________________________________
NAME _______________________________________________________
ADDRESS ________________________________________________________
CITY ________________________________________________ STATE________ ZIP (9 digits)_____________________
Telephone (include area code) (_______)________________________
Fax (include area code) (_______)_________________________
Email ____________________________@______________________________
Date of birth (mm/dd/yyyy) _________/__________/__________
     
EDUCATION
COLLEGE __________________________________________________________________
Degree ________________________________________________________ Year Issued ________________
 
GRADUATE SCHOOL  _______________________________________________________
Degree ________________________________________________________ Year Issued ________________
Please have your graduate school forward your transcript to the Training Committee.
STATE(S) CURRENTLY LICENSED _____________________________________________
License Number(s) _____________________________________________
STATE(S) CURRENTLY CERTIFIED _____________________________________________
Certification Number(s) _____________________________________________
Please submit a copy of your license(s) and certificate(s).
When do you expect to become licensed or certified?______________________________________________
Have you had or is there pending legal or ethical charge against you? Yes No
If yes, please explain on a separate paper.
 
EMPLOYMENT HISTORY (list most recent first) DATES
   
   
   
   

DO YOU HAVE A PRIVATE PRACTICE? Yes No HOW MANY HOURS PER WEEK? ___________

PREVIOUS PSYCHOANALYTIC SUPERVISION DATES FREQUENCY
     
     
     
     



PREVIOUS PSYCHOANALYTIC TRAINING EXPERIENCE DATES
   
   
   
   



PUBLICATIONS
 
 
 
 



PREVIOUS AND PRESENT PERSONAL PSYCHOANALYSIS/PSYCHOTHERAPY
Name of Analyst
Dates
Frequency/Week
     
     
     
     
Please have your analyst send his/her training credentials to the Institute and a letter certifying the dates and frequency of your treatment.

Do you consider your previous treatment experience to have been self psychology oriented? Yes No

REFERENCES
Name
Address
Telephone
     
     
     
Applicants should arrange for three letters of reference to be sent to the Training Committee of the Institute.

How did your learn of NYIPSP? Colleague  Journal Ad  Supervisor/Therapist   Institute Mailing   Website

Application, accompanied by a $50.00 fee, is to be mailed to:

The New York Institute for Psychoanalytic Self Psychology
230 West End Avenue, Suite 1D
New York, New York 10023-3662