Personal Data

Legal First Name

Legal Middle Name

Legal Last Name

Gender

Home Telephone

Business Telephone

Cell Telephone

Residential Address

Permanent Address (same as residential)?

Yes

Note: all correspondence will be sent to permanent address

Profession

University Degree(s)

Professional Qualification(s)

Social Insurance Number

(required for CRA T2202 education & tuition credits certificate)

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 or volunteer work for at least one year. Please have them send a letter of reference detailing their evaluation of your professional and personal qualities.

Name

Address

Occupation

Period Known

Acknowledgments

I understand that I must hold a Certificate of Registration in good standing with the College of Registered Psychotherapy (the CRPO) in order to practise as a psychotherapist in Ontario.

Yes

I understand that I cannot use the protected titles or designation “Registered Psychotherapist” (RP) unless I hold a Certificate of Registration in good standing with the CRPO.

Yes

I understand that the TICP may require additional information (including supporting documents) in connection with this Application Form.

Yes

I understand that if there are any changes to the information provided on this Application Form I am required to notify the TICP within 30 days of that change.

Yes

I understand that I must provide TICP with a certified Vulnerable Sector Screening police check prior to the first day of this training program, at my own expense.

Yes

A Vulnerable Sector Screening is intended for individuals seeking employment or volunteer opportunities with vulnerable persons. A vulnerable person is defined as a person who, because of their age, a disability, or other circumstances, whether temporary or permanent, are (a) in a position of dependence on others or (b) are otherwise at a greater risk than the general population of being harmed by person(s) in a position of authority or trust to them.

A Vulnerable Sector Screening will provide the following information:

1. Criminal convictions summary or indictable from CPIC and/or local databases

2. Findings of guilt under the Youth Criminal Justice Act within the applicable disclosure period

3. Outstanding entries, such as charges and warrants, judicial orders, peace bonds, probation and prohibition orders

4. Absolute and conditional discharges

5. Charges that resulted in a finding of not criminally responsible on account of mental disorder

6. Pardoned offenses authorized under the Criminal Records Act Non-conviction information authorized through Exceptional Disclosure

Summary & Certification

Please send by email or mail along with the completed Application

a) Your academic transcripts *

b) Three confidential letters of recommendation, at least two (2) of which must be from recent supervisors or administrators well-acquainted with your work *

c) A personal account of why you wish to pursue this training, how it relates to your past and future career and life goals. The account should include a history of any experience in the field of mental health, and the reasons you feel able to undertake the training program in your present life circumstances.

d) Application Fee of $250.00 made payable to the “Toronto Institute for Contemporary Psychoanalysis” or “TICP”. This is also payable by e-transfer to info@ticp.on.ca or by credit card online at www.ticp.on.ca Please note: The application fee is not refundable.

e) All applicants will have a minimum of one admission interview. This will be scheduled at a mutually convenient time and will last approximately 45 minutes.

Return Application Items By Mail or Email to:

Suzanne Pearen, TICP Administration Manager

TICP Business Office: 17 Saddletree Trail, Brampton, ON, L6X 4M5

info@ticp.on.ca

* If these documents cannot accompany the application form, please ensure that the materials follow as soon as possible after the application form. Your file must be complete prior to the admission interview.

Apply for 3-Year Psychoanalytic Psychotherapy Program

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

Summary & Certification

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