David Raft Fellowship Application

  • David Raft Fellowship Application

  • Created through a generous gift from Elizabeth Raft, MD, the David Raft Fellowship is awarded to a clinician enrolled in, or planning to enroll in, the training programs of the Psychoanalytic Center of the Carolinas (PCC). The David Raft Fellowship provides up to $1,250 towards training expenses for the upcoming academic year. These funds may be applied to tuition, training program fees, and/or membership dues.

  • Applicant Information

  • Format: (000) 000-0000.
  • How did you hear about this scholarship? (Please check all that apply)*
  • Are you a matriculated student?*
  • What courses interest you the most?*

  • Curriculum Vitae

  • Please provide a current curriculum vitae or other documentation containing the following information, if applicable:

    1. Education: List academic degrees, years awarded, institutions, locations, and majors or areas of specialization.

    2. Clinical training: List sites and dates of all internships, residency programs, fellowships, practicum placements, advanced certificate training, or any other formal supervised training, with names of direct supervisors and dates of supervision.

    3. Professional Experience: Provide all post-training employment with dates and brief descriptions of the nature of the clinical work. Include private practice.

    4. Supervision: List major supervisors, starting and ending dates, frequency, focus (continuous case or most urgent case), and format (individual/group).

    5. Psychoanalytically oriented studies: List coursework, workshops, or other psychoanalytic study, with dates, instructors, and sponsoring organizations.

    6. Other studies and work experience relevant to your interest in psychoanalytic psychotherapy, e.g., work in another field, or independent reading, or research.

    7. Writing: Provide a bibliography of publications and papers presented, and a brief description of any unpublished research, clinical, or theoretical writings.

    8. Teaching Experience: List courses or seminars taught; include dates, locations, sponsoring organizations, and topics.

    9. Supervising Experience: Include dates, locations (e.g., agency, private practice, institute), number of individuals, number of hours, format (individual/group), and types of supervisees (students/professionals).

    10. Professional Affiliations: List names of professional societies and organizations and dates of membership.

    11. Current clinical practice: Include approximate number of clinical hours per week, clientele (adult, child, families, etc.), modes of treatment, types of problems treated, usual frequency of treatment, etc.

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  • Personal Statement

  • Please include a brief personal statement that demonstrates one or more of the following:

    • Interest in the application of psychodynamic principles to any area of clinical care
    • Commitment to developing oneself as a psychotherapist by deepening one's knowledge and understanding of one's own inner processes and by learning to apply that understanding in the therapeutic relationship.
    • Curiosity and intellectual capacity to undertake further psychoanalytic study

  • Representation Section

  • 1. Have you ever been convicted of a crime in any state or country, or are any charges current or pending?*
  • 2. Has any licensing board or professional ethics body ever revoked, restricted or required you to surrender your license or found you guilty of a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state/country, or is any such action current or pending?*
  • 3. Have you ever had any insurance company decline, cancel, refuse to renew or accept only on special terms any professional liability insurance?*
  • 4. Has any professional liability claim, or suit ever been made against you or is any such action current or pending?*
  • 5. Are there any circumstances of which you are aware that may result in any professional liability claim or suit being made against you?*
  • 6. Have you ever been engaged in any sexual conduct with any of your current or former patients or any current or former patient’s spouse or any person with a direct relationship to the patient or former patient (e.g., a guardian, blood relative of the patient or spouse, or any person sharing the patient’s domicile)?*
  • 7. Have you ever had any hospital, agency, health care provider, or professional organization deny, restrict or revoke professional or research privileges or invoke probation for any cause other than incomplete medical charts, or is any such action current or pending?*
  • 8. Have you ever been suspended, restricted or put on probation by any governmental health program (i.e. Medicare or Medicaid)?*
  • 9. Are you now or have you ever been treated for alcoholism or other drugs?*
  • 10. Have you ever abused alcohol or drugs?*
  • 11. Have you ever been censured by or dismissed from any professional organization?*

  • Certification

  • I certify that all information provided on this Application, or submitted with it, is accurate to the best of my knowledge. I specifically authorize the Psychoanalytic Center of the Carolinas and its authorized representatives to consult with the third parties whose names I have given either herein or otherwise, as well as with any third parties whose names I may in the future provide as references, concerning further information bearing on my application. I release from any and all liability the Psychoanalytic Center of the Carolinas and their authorized representatives, and any third parties whose names I have provided or may provide, for any acts, communications or disclosures involving me, including otherwise privileged and confidential information relating to me and this application. I acknowledge that the Psychoanalytic Center of the Carolinas reserves the absolute right to accept or reject any applicant for any reason(s) deemed sufficient by the Psychoanalytic Center of the Carolinas in its sole discretion.

    I also understand that a letter of reference is required as part of my application for the Raft Fellowship and that information contained in such letters will be kept confidential in accordance with the Confidentiality Policy of the Psychoanalytic Center of the Carolinas. By submitting this completed application, I give consent to the named reference above to provide information regarding me to representatives of the Psychoanalytic Center of the Carolinas.

  • I understand that I may have a legal right of access to letters of reference. For the purposes of encouraging full and candid disclosure by the referring individual, I hereby authorize the release by him/her to the Raft Fellowship selection committee of the Psychoanalytic Center of the Carolinas of any and all information that may be requested, and I waive any right of access that I otherwise might have to his/her statements and information, and agree that these statements and information shall remain completely confidential.

  • If you have questions about the fellowship program and your eligibility, please contact Lucy Worth at lucyworth@carolinapsychoanalytic.org. 

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