Form B - Psychoanalyst Qualification Form - Tampa Bay Institute for Psychoanalytic Studies

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Enter Candidate Name

First

Last

The above-named candidate has provided your name as their personal psychoanalyst and has authorized TBIPS to contact you to verify the following information. Please complete the form below.

Analyst Name

First

Last

Analyst Phone

Analyst Email

Date Treatment Began

Sessions Per Week

PSYCHOANALYTIC AFFILIATIONS OF ANALYST

Name and Address of Training Institute and Date of Graduation:

Courses Taught, Committees Served On, and/or Publications:

Years of Experience as a Practicing Psychoanalyst:

ATTESTATION

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