Four-Year Program Application

Training Program in Psychoanalysis
(Fee $55)
Applicant Information
Name*
First M.I. Last
Date of Birth*
Date Format: MM slash DD slash YYYY
City of Birth*
Preferred Pronoun
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*

Office
Professional Title (e.g., Psychiatrist, Psychologist, Social Worker, etc.)
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Phone Number
Office Email

Personal Psychotherapy: Therapist
Name
First Last
Orientation
Dates
# of Hours
Psychoanalytic Training Institute
Date of Completion
Date Format: MM slash DD slash YYYY
Please Note: In order for your present therapist to be acceptable as your IPSS training analyst, he/she must be a graduate of a recognized psychoanalytic training institute with a minimum of five years postgraduate experience.

Psychotherapy Supervision
Supervisor Address # of Hours Type of Therapy Dates
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.

Paid Work Experience to Date
Organization Supervisor Hours Worked Type of Work Dates
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.

Present Psychotherapeutic Work
Nature of Work
Ages and Types of Patients
Nature of Work
Present Supervisor(s)
First Name Last Name
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.
Hours Per Week Engaged in Psychotherapy:
Privately
In Institutions or Agencies

Additional Information
Publications
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.
Title of Thesis or Dissertation
Research Interests
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.
Professional Licenses or Certificates
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.
Professional Affiliations
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.
Honors, Awards, Scholarships
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.
Extracurricular and Community Activities
Please Note: hit the plus sign (+) at the end of the row above to add an additional row.

References
Please list three references: Two employers and a current supervisor. Please have these letters of reference forwarded to IPSS.
Full Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Full Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Full Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

How did you learn about IPSS's Training Program?
Did you attend the Open House?
- Yes
- No
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
Signature
Please Type Your Name Below*
Date: 12/21/2024
Please note: Upon submitting your application, you will be directed to a payment page in which you can pay the $50 application fee online. You will also receive an email with a link to a webpage where you can upload additional required materials, which include:
- Transcripts of all undergraduate and graduate work
- A copy of your current malpractice insurance certificate (In most cases insurance may be obtained from the American Professional Agency, 95 Broadway, Amityville, NY 11701, 631-691-6400.)
- A copy of your NYS License
- Your current psychoanalyst’s vita for approval (Your therapist must be licensed in his/her field and be a graduate of a recognized psychoanalytic training program with at least five years of post-graduate experience.)
- A typed personal statement, not to exceed one page in length with a minimum font size of 10 point
Personal Statement Upload
A typed personal statement, not to exceed one page in length with a minimum font size of 10 point

Supervisor	Address	# of Hours	Type of Therapy	Dates

Organization	Supervisor	Hours Worked	Type of Work	Dates

First Name	Last Name

Training Program in Psychoanalysis