Fellowship Application

Company

This field is for validation purposes and should be left unchanged.

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

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

An application fee is required with the submission of the Fellowship application. Choose the one that is appropropriate:

Professionals
Residents, Interns, and Graduate Students
International Applicants (Outside of US)

Total

$0.00

Credit Card*

Card Details

Cardholder Name

Fellowship Application Form

Fellowship Application Fee