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

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Application Form - Psychoanalytic 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
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Max. file size: 256 MB.
Attach a Copy of your Professional License
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 files here if you do not have adequate room in the designated spaces above
Drop files here or
Max. file size: 256 MB.
Autobiographical Statement
Your autobiographical statement should be approximately five pages indicating your reasons for pursuing psychoanalytic training, aspects of your personal and childhood history including family background and later development, relative strengths and weaknesses, future professional plans including the possibility of relocation.
Drop files here or
Max. file size: 256 MB.
Contact Information for References
Please indicate the names and addresses of three mental health Professionals who are familiar with your work to serve as references. Please ask them to send letters to ICP+P Psychoanalytic Training Program, 3298 Governor Drive, Suite 22270, San Diego, CA 92192.
References #1
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email - Reference #1
References #2
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email - Reference #2
References #3
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email - Reference #3
Application Fee - Psychoanalytic Training
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:
Phone
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Application for the Psychoanalytic Training Program — Payment by Check

Application Form - Psychoanalytic Training (Check)

Contact Information for References

References #1

References #2

References #3

Application Fee - Psychoanalytic Training