New Psychodynamic Psychotherapy Application

Psychodynamic Psychotherapy Application

Application Instructions

Please fill in the fields below. Each applicant will be contacted by a member of the Admissions Committee to complete a personal interview as part of the process. Along with the application and $200 Application Fee (non-refundable), please submit the following items:

*Curriculum Vitae/Resume
*Copy of most recent academic transcripts
*Copy of license and certificate of malpractice insurance
*(2) Professional Letters of Reference
*Personal Statement (no more than 600 words)

First Name

Preferred Name

If you prefer to be called by a name other than your first name, enter it here.

Last Name

Degree

Bachelors (BA,BS)

Masters (MA, MS, MSW, MEd)

Doctorate (PhD, PsyD)

Medical Doctor (MD, DO)

Street

City

State/Province

Zip/Postcode

Cell Phone

Country

Additional Information

If you live outside the Chicago area, please choose YES to being a Distance Student.

Distance Student

Yes No Not Selected

Country of Citizenship

License Type:

Other License Type Detail

If other, please specify

License #:

License Expiration:

For Reporting Purposes Only

Ethnicity

Birth Date

Gender

Other Gender Identities

If you identify as something other than man or woman, enter your identity/pronouns in this field.

Admission Documents and Information

We do not require Letters of Reference or transcripts to be sent anonymously or by the outside institutions. They can be uploaded with this application or emailed to education@chicagoanalysis.org

Copy of Professional License

Required for: PEP, PSP, PPP

Name of Insurance Company

Policy Number

Professional Liability Insurance Expiration:

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

Required for: PEP, PSP, PPP

Most Recent Transcript

Required for all programs EXCEPT Open Classes and Exploring Psychoanalysis

Curriculum Vitae/Resume

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

Auto Charge?

Yes No Not Selected

Enter the above code

Required