Application Form - Four Year Psychoanalytic Training Program - IPSS – The Institute for the Psychoanalytic Study of Subjectivity

Four-Year Psychoanalytic Training Program

Online Application

Thank you for filling out this application for the Four-Year Psychoanalytic Training Program. The application due date for the upcoming cohort is July 15th.

The application fee is a non-refundable $60. You will receive a confirmation email upon receipt of your application. If you haven’t received the confirmation email, please check your spam folder.

The non-refundable $60 application fee can be paid in one of two ways:

Zelle: ipssny@ipssny.org
Check: Make payable to IPSS, with “Application Fee, Foundations Program” in the memo. Mail to:
IPSS
71 West 23rd Street
Suite #1400
New York, NY 10010

Letters of recommendation can be sent to ipssny@ipssny.org

Step 1 of 10

Training Program in Psychoanalysis
(Fee $60)
Applicant Information
Name*
First M.I. Last
Preferred Pronouns
Date of Birth*
MM slash DD slash YYYY
City of Birth*
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

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

Supervisor	Address	# of Hours	Type of Therapy	Dates

Organization	Supervisor	Hours Worked	Type of Work	Dates

Four-Year Psychoanalytic Training Program

Online Application

Step 1 of 10

Training Program in Psychoanalysis

Applicant Information

Education

Office

Personal Psychotherapy: Therapist

Psychotherapy Supervision

Paid Work Experience to Date

Present Psychotherapeutic Work

Additional Information

References

Disclaimer and Signature

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First Name	Last Name