Application for the Couples Therapy Training Program - Payment by Check - Institute of Contemporary Psychotherapy and Psychoanalysis

Please complete the form below to apply to the Couples Therapy Training Program. Any questions can be directed to Michael Wannon at menaw1@aol.com.

An application fee of $50 needs to accompany this application. Complete the application on this page if you prefer to pay by check. If you prefer to pay by credit card, please click here to go to the application page for credit card payments.

Application Form - Couples Therapy Training (Check)

Name*
First Last
Date of Birth
MM slash DD slash YYYY
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone Number
Email*
Business Address
Street Address Address Line 2 City State ZIP Code
Business Phone
Preferred Mailing Address
- Home Address
- Business Address
Attach a Copy of your most recent CV
Drop files here or
Max. file size: 256 MB.
Current Malpractice Insurance Coverage
Please list your current insurance carrier.
Attach a Copy of your Current Malpractice Insurance Coverage
Drop files here or
Max. file size: 256 MB.
Education
List the College/University you attended, your Major, # of Credits, Degree and Date of Graduation.
Mental Health Training (Internships, Residencies, Institutes, etc.)
List the name of the Institution, Course/Programs, Dates and Supervisors.
Clinical Experience
List your training & professional experiences, listing most current first. Include Dates, Client Age Range, Treatment Modality, Setting (Hospital/Clinic), Hours per Week, and Supervision (Type, Individual, Peer, Group, etc., and Frequency).
Other Professional Activities
e.g. research, teaching, community work, writing, etc.
Personal Psychotherapeutic and/or Psychoanalytic Experience
List the type of psychotherapy (individual, family, couples, group), the therapist's name(s) and theoretical orientation(s), when, how often, and how long.
Attach any additional information here
If you do not have adequate room in the designated spaces above, use this space to upload anything else you want to share.
Drop files here or
Max. file size: 256 MB.
Couples Application Fee
Application Fee*
A $50 application fee is required with the submission of the training application. This fee is non refundable, but will be applied to your tuition. You have chosen to pay the application fee with a check. Please make the check payable to ICP+P and send to ICP+P, 3298 Governor Drive, Suite 22270, San Diego, CA 92192.
Price:
Name
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Application for the Couples Therapy Training Program — Payment by Check

Application Form - Couples Therapy Training (Check)

Couples Application Fee