JumpStart Psych
Psychotherapy Essentials Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Graduate Healthcare Education
Institution:
*
Degree:
*
Major / Field of Study:
*
Graduation Year:
*
Professional Experience
I currently work in the following setting(s):
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Outpatient Private Practice (owner)
Outpatient Group Practice (employee/contractor)
Inpatient Psychiatry
Inpatient Consultation Service
Detox / Rehab (Substance Use Disorders)
Current Student
Other
I specialize in one or more of the following:
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General Psychiatry
Child-Adolescent Psychiatry
Addiction Psychiatry
Consultation-Liaison Psychiatry
Geriatric Psychiatry
Forensic Psychiatry
Current Student
Other
How many patient encounters do you currently have on a weekly basis?
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1-5
5-10
10-15
15-20
20-30
30+
Other
Psychotherapy Practice and Knowledge Assessment
Please rate your comfort and confidence level in clinical practice for each of the six (6) psychotherapy modalities we will be covering in this fellowship:
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1
2
3
4
5
Supportive Psychotherapy
Motivational Interviewing
Cognitive Behavioral Therapy
Mindfulness-based Techniques
Psychodynamic Psychotherapy
Dialectical Behavior Therapy
Personal Statement
Please provide a personal statement for each of the following points:
1. Motivation: What inspired you to pursue psychotherapy training? Why now?
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2. Experience: Describe your clinical experience and how it has prepared you for this psychotherapy fellowship track.
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3. Goals: What are your short-term and long-term professional goals? How will this fellowship help you achieve them?
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4. Personal Qualities & Attributes: Please describe your ability to empathize with patients and provide compassionate care.
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Curriculum Vitae
Please upload a copy of your CV here:
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Consult Call
As the final step of the application process, applicants are required to schedule a consultation call with Dr. Geoffrey Talis. This call provides an opportunity to discuss your application in more detail, clarify any questions, and further assess your suitability for the fellowship. To schedule your consultation, please schedule a time below. Your application will not be considered if you do not appear for your scheduled Consult Call.
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Signature
I hereby certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation, omission, or falsification of information may result in the disqualification of my application or termination from the fellowship program if discovered at a later date. I authorize the JumpStart Psych Fellowship Program to verify any information provided in this application.
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