Form C - Supervisor Qualification Form - Tampa Bay Institute for Psychoanalytic Studies

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Candidate Name

First

Last

The above-named candidate has provided your name as for consideration as a supervisor of their psychoanalytic training cases. Please complete the form below and forward your resume to TBInstitutepsastudies@gmail.com..

Supervisor Name

First

Last

Supervisor Phone

Supervisor Email

List Degrees

License Number & State

PSYCHOANALYTIC AFFILIATIONS

Name and Address of Training Institute and Date of Graduation:

Institutes with which currently affiliated

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

Years of Experience as a Practicing Psychoanalyst:

Years of Experience as a Supervising Analyst or Psychoanalytic Psychotherapist

Number of candidates supervised over the years

Experience with telephone/Skype supervision

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 potential Supervisor 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.