Advanced 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.

Cancelof
Previous Therapists and/or Analysts

Applicants to the Training Program invariably 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. 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
Analyst/Therapist Name and Location
Type of Treatment and Frequency
Beginning and Ending Dates
Analyst/Therapist Name and City
Type of Treatment and Frequency
Beginning and Ending Dates
If others, add them here
Advanced Psychoanalytic Experience
Detail Experience in Psychoanalytic Theory and Teaching *
An advanced candidate will have shown an application of psychoanalytic theory via years of teaching and writing in the field beyond their graduate program. They would ideally have a minimum 5-10 years of serious teaching of psychoanalytic theory and clinical practice. List specific courses that have been taken and/or taught. Uploads may be included in the section below.
Psychoanalytic Writing and Presentations*
An advanced candidate will have published and/or presented at professional conferences and have demonstrated a serious engagement with psychoanalytic theory and clinical practice. Papers can be upload in the section below.
Additional Details and Uploads
Current Curriculum Vitae (see note below)*

Cancelof
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. Clinical Training: List site and dates of all internships, residency programs, practicum placements, advanced certificate training, or any other formal supervised training with names of direct supervisors and dates of supervision. Professional Experience: Provide all post-training employment, dates, and brief description of the nature of the clinical work. Include private practice, and list supervisors and dates of supervision where applicable. 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.
Cancelof
Post-degree Psychoanalytic 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.
Cancelof
Transcripts of all Graduate Work

Cancelof
Current Copy of Professional License

Cancelof
Letters of Reference

Please provide at least three letters of reference from supervisors, colleagues, or other professionals who are very familiar with your professional and clinical work (other than your analyst/therapist). At least one of these references should be from a current individual supervisor. Please ask each to write in detail regarding your suitability for psychoanalytic training at an advanced level. 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. It need not be in a sealed envelope. We require three, but you may provide additional letters of reference. We may contact your references for additional information about your work.
Cancelof
Teaching Syllabi

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

Please upload relevant papers you have published.
Cancelof
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.
Cancelof

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

Advanced Psychoanalytic Experience

Additional Details and Uploads

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

Scholarships and Financial Hardship