One-Year Distance Learning Program Application

Application due date is June 15th, 2022. Tuition is $1,800.00. Tuition can be paid in 2 installments—with 50% due August 1, 2022, and the remaining 50% due December 30, 2022. Classes are held live online via Zoom: on Mondays at 10 - 11:30 AM (EST), from September 12, 2022 through May 2023, for a total of 24 classes. Dates and times, detailed separately here are subject to change.
Applicant Information
Name*
First M.I. Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Phone Number*
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
City of Birth*
Professional Title and License (e.g., Psychologist, Social Worker, Psychiatric Nurse, Teacher, etc.):

Professional Reference
Full Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

PERSONAL STATEMENT*
Please provide a one-paragraph Personal Statement about your clinical experience and why you want to join IPSS Distance Learning.
CURRICULUM VITAE*
Accepted file types: doc, docx, pdf.
Please upload your C.V. or professional biography with this application as a PDF or Word doc. (5MB Max)

Applicant Information