Psychoanalytic Psychotherapy Programs Online Application

Please indicate which program(s) you are applying to: *1 Year - Psychoanalytic Psychotherapy Program: Adults1 Year - Psychoanalytic Psychotherapy Program: Couples1 Year - Psychoanalytic Psychotherapy Program: Infants, Children and Adolescents

First and Last Name *

Email Address *

Today's Date *

Month

Day

Year

Home Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Home Phone *

Office Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Office Phone

Mailing address: Home or Office? *HomeOffice

California License or Registration Number *

Date you began receiving monetary compensation as a clinician *

Month

Day

Year

Have you ever:Been denied or asked to resign membership with another institute?Been a subject of a malpractice lawsuit?Had a grievance filed against your license?Had an ethics grievance been filled with your professional association?

If you checked yes to any of the questions on the left, please provide an explanation below:

Please upload a photocopy of professional license *

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Applicants practicing under another’s license must provide a copy of that license and a letter from that license holder authorizing participation in the Institute Program.

Please upload a photocopy of face sheet of current Malpractice Insurance Policy *

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Please upload three letters of recommendation to be sent to directly to the Institute *

Please use Institute forms provided with application packet.

Please upload a signed Certificate of Understanding *

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Please upload your Autobiography *

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This is an opportunity for you to tell your story. Please take a minimum of 3-4 double spaced pages to reflect on the life experiences and the psychological development that has brought you to this moment of making application to a psychoanalytic institute. Your autobiography will be read before your first interview with the Director of Admissions to help her/him get to know you.

Please upload your Professional Vitae (to include the following): Clinical training and work experience (setting, population, individual responsibility, supervision received (include all internships)), Current employment (Please include place of work, the nature and description of your position), Other professional interests and activities (i.e. research teaching, community work and publications) *

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