Applications are now CLOSED for 1-Year Essentials of Psychoanalysis Program

Professional Data

Name of Employer

Position Held

Dates of Employment

Name of Employer

Position Held

Dates of Employment

Name of Employer

Position Held

Dates of Employment

Relevant Professional Papers / Contributions (optional, not required for admission)

Title, Publication/Conference, and Date

Previous training in Psychotherapy (optional, not required for admission)

Courses and Supervision

Memberships (optional, not required for admission)

Societies, Professional Bodies of which you are a Member or Fellow:

Professional Affiliations & Licensure

Are you currently registered/licensed, or have you ever been registered/licensed by another regulatory/licensing organization in any profession in any jurisdiction?

Yes

Please provide details:

Have you ever been refused registration or membership by a regulatory/licensing body?

Yes

Please provide details:

Have you ever resigned your membership or registration with a regulatory/licensing organization while you were the subject of a complaint, investigation or proceeding with respect to professional misconduct, incompetence or incapacity in the practice of any profession (in any jurisdiction)?

Yes

Please provide details:

Have you ever been charged with misconduct, including academic misconduct, that resulted in disciplinary actions by an educational institution while you attended a post-secondary institution?

Yes

Please provide details:

References

Provide the names and addresses of three individuals who have known you well in your professional
work for at least two years. Please have these individuals send a letter of reference at the time of your
application, detailing their evaluation of your personal qualities and psychotherapeutic work.

Name

Address

Occupation

Period Known

Personal Data

Professional Data

Relevant Professional Papers / Contributions (optional, not required for admission)

Previous training in Psychotherapy (optional, not required for admission)

Memberships (optional, not required for admission)

Professional Affiliations & Licensure

References