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 June 15th, 2024.

After you have submitted your application, you will be directed to the payment portal. The application fee is a non-refundable $(auto generated). You will receive a confirmation email upon receipt of your application and payment.

Step 1 of 10

Training Program in Psychoanalysis
(Fee $55)
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