New Child & Adolescent Psychotherapy Program Application (Deactivated)

Child & Adolescent Psychotherapy Program Application (Deactivated)

APPLICATION FOR ENROLLMENT

Please fill in the items below. Along with the application and $100 Application Fee (non-refundable and made out to Chicago Psychoanalytic Institute), please submit the following items:

*Copy of most recent academic transcripts
*Copy of Curriculum Vitae or resume
*Copy of license and certificate of malpractice insurance (must be submitted prior to start of program)
*(2) Letters of Reference (from Professional Contacts)
*Personal Statement (no more than 1,000 words)

First Name

Middle Name

Last Name

Street

City

State/Province

Zip/Postcode

Country of Citizenship

Cell Phone

Home Phone

For Reporting Purposes Only

Birth Date

Gender

Ethnicity

PROFESSIONAL ADDRESS:

Work Address

Work City

Work State/Province

Work Zip/Postal Code

Work Phone

Emergency Contact Information

Private Practice Experience

License Type:

Name of Insurance Company

Policy Number

Admission Documents

Curriculum Vitae/Resume

Most Recent Transcript

Required for all programs EXCEPT Open Classes and Exploring Psychoanalysis

Copy of Professional Liability Insurance (Please upload a new copy each year)

Required for: PEP, PSP, PPP

Professional Liability Insurance Expiration:

License #:

License Expiration:

Copy of Professional License

Required for: PEP, PSP, PPP

Letter of Reference 1

Required for all programs EXCEPT Open Classes

Letter of Reference 2

Required for all programs EXCEPT Open Classes and Exploring Psychoanalysis

Brief Personal Statement

Payment options

If you select the ACH or Bank Transfer Payment method, the Institute will email you an Invoice which will contain a payment link. The Transaction fee will be 1.5% of the Total Balance or $1.00, whichever is larger.
If you select payment by Credit or Debit card, after you click the Submit Application button, you will be directed to a payment page to enter your card information. Students paying by ACH or Bank Transfer will need to ignore the Payment page.

Please select your Payment Method here:

(Please skip this section if you chose ACH or Bank Transfer option above.)
Would you like your Credit/Debit card auto charged? This allows us to save your card information to process future payments.

Auto Charge?

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