Application Form for the Fellowship Program

Please complete the form below to apply to the Fellowship Program.

An application fee of $50 for professionals and $30 for residents, interns, and graduate students needs to accompany this application. Your credit card details will be collected at the bottom of the form.

Any questions can be directed to Adriana Couto Silva, MS, MA, LCPC, asilvapsychotherapy.com or Eileen Boyle at dreileenboyle@gmail.com.

Fellowship Application Form

Name*
First Last
Preferred Pronouns
Examples include but are not limited to she/her/hers, he/him/his, they/them/theirs, etc.
Professional suffix you prefer after your name
Examples include but are not limited to LICSW, LPC, MA, MD, MSW, PhD, PsyD, etc.
Under what profession are you licensed?
If you are not licensed or your license type is not specifically listed, please select "Other."
Date of Birth
MM slash DD slash YYYY
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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
Education
List the College/University you attended, your Major/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. Please describe the modalities of treatment provided, ages of clients, length and frequency of treatment, and type and frequency of supervision received.
Other Professional Activities
e.g. research, teaching, community work, writing, etc.
Brief Statement of Interest
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.
Attach files here if you do not have adequate room in the designated spaces above.
Drop files here or
Max. file size: 256 MB.
Please feel free to request accommodation in the space below.
If you will need accommodations, please contact our Administrator at administrator@icpeast.org.
Fellowship Application Fee
Fellowship Application Fee
An application fee is required with the submission of the Fellowship application. Choose the one that is appropropriate:
- Professionals
- Residents, Interns and Graduate Students
Total
$0.00
Credit Card*
Card Details
Cardholder Name
Name
This field is for validation purposes and should be left unchanged.

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Fellowship Application Form

Fellowship Application Fee