PSYCHOANALYTIC CENTER OF PHILADELPHIA

Psychoanalytic center of philadelphia

Psychodynamic Psychotherapy Training Program

Application for Training

ADULT PROGRAM _______ CHILD PROGRAM _______

Name_______________________________________________________________ Date of Birth _____________________

Office Address _________________________________________________________________________________________

Home Address _________________________________________________________________________________________

Office Telephone_________________________________ Home Telephone ______________________________________

Email Address __________________________________________ Fax _________________________________________

Education (Graduate and Undergraduate):

School ___________________________________________ Degree ______________ From _______ To____________

Residencies, Internships, Professional Training:

(State type of program, Institution, Dates)

______________________________________________________________________________________________________

Other past professional experience:

(Clinical Work, Teaching, Research, Post-Graduate Courses)

______________________________________________________________________________________________________

Present Professional Activities:

______________________________________________________________________________________________________

Current Academic and Hospital Appointments and Professional Society Memberships:

______________________________________________________________________________________________________

Professional License(s):

______________________________________________________________________________________________________

Certifications: ______________________________________________________________________________________

Experiences as a Patient in Psychotherapy or Psychoanalysis:

(Type(s) of treatment, name and location of therapist or analyst, number of sessions per week, dates started and completed.)

______________________________________________________________________________________________________

Social Work Applicants:

If you wish to be considered for a scholarship, please submit a letter stating your reasons for applying for tuition assistance and sign the following statement:

I authorize the scholarship committee to review my application materials.

_______________________________________________

Signature of Applicant

_____________________________

       1. Please include with your application:

         a. An autobiographical sketch of preferably no more than 2 pages, including a statement of your
reasons for wanting to pursue training in psychoanalytic psychotherapy.

          b.   Evidence of current liability insurance and licensure (if applicable).

          c.   A resume.

     2. Please supply two letters of reference from supervisors familiar with your work.

     3. All materials are preferred by June 30 for September classes. Applications are considered without
           regard to race, sex, religion, age, national origin, sexual preference, or physical disability. Admission
           decisions are made by the Administrative Faculty. Application materials will be treated confidentially.

     4. Enclose $50 nonrefundable application fee payable to: Psychoanalytic Center of Philadelphia.

5.   Please mail to: Rockland – East Fairmount Park, 3810 Mt. Pleasant Drive, Philadelphia, PA 19121

                              Attention: Director, Psychodynamic Psychotherapy Training Program



     6. We look forward to receiving your application.

                                                                                                                        Date

Text Box: The Psychoanalytic Center of Philadelphia does not discriminate on the basis of race, color, religion, gender, national or ethnic origin, political affiliation, sexual orientation, marital status, disability or age, in administration of its educational policies, admission policies, scholarship and loan programs.