Academic Training Program Application

Personal Details
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Degree (include date received)*
Current primary position*
When did you begin this position?*
Address of primary position

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you independently licensed?*

YesNoNA
Board and License Number
Have you ever had your license suspended or revoked?*

YesNoNA
Have you ever been involved in a malpractice suit?*

YesNoNA
Have you ever been sanctioned or dismissed by any hospital, mental health, or professional organization for ethical violations?*

YesNoNA
Since you answered yes to one of the above questions, please upload a separate document explaining why you did.

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Previous Therapists and/or Analysts

Applicants to the Training Program for Academics may have experience being in personal psychotherapy and/or psychoanalysis. In the following section, please complete basic information about your past and present individual therapists and/or analysts, if relevant. We will not be contacting any of them. This confidential information will be reviewed only by Admission Committee Co-Chairs and will otherwise be redacted from your application.
Analyst/Therapist Name and Location
Type of Treatment and Frequency
Beginning and Ending Dates
If others, add them here
Additional Details and Uploads
Current Curriculum Vitae (see note below)*

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Please include ALL of the following information on your Curriculum Vita:

Education: List academic degrees, years awarded, institutions, location, and major or area of specialization. Professional Experience: Provide all relevant employment, dates, and brief description of the nature of the work. Publications: Provide a list of publications, or unpublished clinical/theoretical writings. Teaching: Provide courses titles, location/institution, date(s), and a brief description of the course or seminar, if applicable. (If this was a semester-course, please also include a copy of the syllabus).
Personal Statement*

We are interested in learning about your decision to enter this program at this time. How do your experiences and background relate to your interests and goals? We recommend a 2-4 page statement.
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Post-degree Studies

List coursework, workshops, or other psychoanalytic study taken beyond your highest advanced degrees. Include any other studies and/or work experience relevant to your interest in psychoanalysis.
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Transcripts of all Graduate Work

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Current Copy of Professional License (if obtained)

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Letters of Reference

Please provide at least three letters of reference from supervisors, colleagues, or other professionals who are very familiar with your professional work (other than your analyst/therapist, if applicable). Their letter should be addressed to the Admissions Committee and sent along with your completed application, unless he or she prefers to send it to us directly. We require three, but you may provide additional letters of reference. We may contact your references for additional information about your work.
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Teaching Syllabi

Send copies of previous class syllabi. If you taught a workshop/seminar with no syllabus, you may use an outline or description.
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Published Papers

Please upload relevant papers you have published.
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Scholarships and Financial Hardship
Please indicate if the cost associated with training represents a financial hardship and you are interested in a small scholarship to help with funding.*

YesNo
Scholarship Request Essay

Please provide a concise essay detailing the financial challenges you may be facing. This information will be carefully evaluated by the finance committee, and a scholarship may be offered upon acceptance into the program. Please be assured that your application for a scholarship will not impact the admission decision for the program.
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My Products

Training Program Application FeeThis application fee is non-refundable.

$130.00

Total

$0.00

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Personal Details

Previous Therapists and/or Analysts

Additional Details and Uploads

Please include ALL of the following information on your Curriculum Vita:

Scholarships and Financial Hardship