Application Form for the Fellowship Program — Payment by Check2017-05-16T16:13:14+00:00

This form is for registration and payment by check.  If you prefer to pay by credit card, please click here.

Fellowship Application Form (Check)

  • List the College/University you attended, your Major/Degree and Date of Graduation.
  • List the name of the Institution, Course/Programs, Dates and Supervisors.
  • List your training & professional experiences. Please describe the modalities of treatment provided, ages of clients, length and frequency of treatment, and type and frequency of supervision received.
  • e.g. research, teaching, community work, writing, etc.
  • Describe your reasons for applying to the program, e.g. its relevance to your work, its relationship to career goals, your interest in psychoanalysis, etc.
  • Drop files here or
    • Application Fee

    • An application fee is required with the submission of the Fellowship application. Choose the one that is appropropriate: You can mail a check made out to ICP+P and send to Monica Meerbaum, PhD, Fellowship Program Chair, 4915 St. Elmo Ave., Suite 404, Bethesda, MD 20814.
    • $0.00
    • This field is for validation purposes and should be left unchanged.