New York Institute for Psychoanalytic Self Psychology

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Application for Psychoanalytic Training
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DATE______________

NAME____________________________________DEGREE___________________

ADDRESS_________________________________DATE OF BIRTH____________

CITY________________STATE__________ZIP________PHONE______________

EDUCATION:

COLLEGE & DEGREE______________________________YR. ISSUED_________

GRADUATE EDUCATION____________________________YR. ISSUED_________

Please have your graduate school forward your transcript to the Training Committee.

CURRENTLY LICENSED OR CERTIFIED
IN NEW YORK OR ANY OTHER STATE?__________________________________

WHEN DO YOU EXPECT TO BECOME
LICENSED OR CERTIFIED?______________________________________________

EMPLOYMENT HISTORY (LIST MOST RECENT FIRST) DATES

___________________________________________________ _________

DO YOU HAVE A PRIVATE PRACTICE _______ YES ________ NO

HOW MANY HOURS PER WEEK?___________

PREVIOUS PSYCHOANALYTIC SUPERVISION DATES FREQUENCY

_______________________________________ _________ _______________

PREVIOUS TRAINING EXPERIENCE IN SELF PSYCHOLOGY DATES

___________________________________________________ ___________

PUBLICATIONS:

_________________________________________________________________

PREVIOUS PERSONAL PSYCHOANALYSIS/PSYCHOTHERAPY:
NAME OF ANALYST DATES FREQUENCY/WEEK

____________________________________ __________ ______________

DO YOU CONSIDER YOUR PREVIOUS TREATMENT EXPERIENCE
TO HAVE BEEN SELF PSYCHOLOGY ORIENTED?________________________

REFERENCES:

NAME ADDRESS PHONE

______________________________________________________________________

Applicants should arrange for three letters of reference to be sent to the Training Committee of the Institute.

How did your learn of NYIPSP?

Colleague ____ Journal Ad ____ Supervisor/Therapist ____
Institute ____ Mailing ____

Please mail application and a $50.00 fee to:

The New York Institute for Psychoanalytic Self Psychology
230 West End Avenue, Suite 1D
New York, New York 10023-3662