Application for Training - Tampa Bay Institute for Psychoanalytic Studies

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Psychoanalytic

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Psychoanalytic psychotherapy

Email

Home Phone

Work Phone

Birthdate

International Address

ACADEMIC BACKGROUND

Please forward academic transcripts

Institution 1

List Institution Name, Degree Awarded, Major & Dates

Institution 2

List Institution Name, Degree Awarded, Major & Dates

Institution 3

List Institution Name, Degree Awarded, Major & Dates

Institution 4

List Institution Name, Degree Awarded, Major & Dates

Layout

Previous Psychoanalytic Institute (if any)

Dates Attended

PROFESSIONAL BACKGROUND

Licensure and/or Certifications (Indicate states and type):

Professional Affiliations

If employed in mental health field, list the name of your agency or employer and provide a brief description of your work.

If in private practice, describe the nature of your practice including the populations served, treatment modalities, and length of time in practice.

Describe any additional work experience or specific skills (including areas not directly related to psychotherapy or mental health):

PERSONAL PSYCHOANALYSIS or PSYCHOTHERAPY

Name of Analyst/Therapist & Degree

Dates of Treatment & Sessions per Week

PROFESSIONAL REFERENCES

List two individuals (other than your analyst or therapist, past or present) who are in a position to comment on your professional work and your suitability for training.

Include Name, Address, Dates & Nature of Relationship

Please have each reference complete Form B and forward to the address indicated.

Reference 1

Reference 2

PERSONAL STATEMENT

Please submit a personal statement (4-7 pages) which would include how events and circumstances in your own life have contributed to your interest in psychoanalytic training. Please include an assessment of your strengths and weaknesses along with a description of how you feel the training may assist with your professional goals, and any other reasons you may have for seeking training.

Please include the following with your completed application:

Current copy of your Curriculum Vitae
Copy of your FL state mental health services license and/or certifications
Copy of your current malpractice insurance certificate
Personal Statement (see description above)
Transcripts from undergraduate and graduate educational institutions
Professional references (Form B) should be forwarded directly from the recommender to TBIPS.

Send all application materials (via email or regular mail) to:

Tampa Bay Institute for Psychoanalytic Studies

tbinstitutepsastudies@gmail.com

3404 62nd St E

Bradenton, Florida 34208

USA

ATTESTATION

By checking this box I attest that all the information provided in this application form is true and verifiable, and that I am the person identified as the applicant for training. I understand that any false representation of my identity or qualifications in this application can disqualify me for consideration for training by TBIPS.