TAMPA BAY INSTITUTE 
FOR PSYCHOANALYTIC STUDIES, INC
                 (TBIPS)

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TAMPA BAY INSTITUTE FOR PSYCHOANALYTIC STUDIES                                

13919 Carrollwood Village Run,

Tampa, Florida 33618

Phone: (813)908 – 5080                  end_of_the_skype_highlighting Email: tbinstitutepsastudies@gmail.com  begin_of_the_skype_highlighting

Website: www.tampapsychoanalytic.org/tbips.html

 

Application for Training

 

 

Name (print) _________________________________________________________________

Address Home ____________________________________________________________

_________________________________________________________________

Business __________________________________________________________

_________________________________________________________________

Phone Home (___)____________________ Business (____) _____________________

Email _____________________________ Fax (____)__________________________

Birthdate __________________ Age _____ Social Security Number _________________

 

ACADEMIC BACKGROUND

Institution

Degree Awarded

Major

Dates













 

Previous psychoanalytically oriented studies, if any:

Institution___________________________________Dates of Attendance__________________

Courses completed (list courses or attach transcript)

 

 

PROFESSIONAL BACKGROUND

1. Licensure and/or Certifications (Indicate states and type):

 

2. Professional Affiliations

 

 

3. If employed in mental health field, list the name of your agency or employer and provide a brief description of your work.

 

 

 

4. If in private practice, describe the nature of your practice including the populations served, treatment modalities, and length of time in practice.

 

 

 

5. Describe any additional work experience or specific skills (including areas not directly related to psychotherapy or mental health):

 

 

 

Briefly describe your interest in psychoanalytic practice and thought

 

 

 

 

I am interested in: (please check all that apply)

Psychoanalytic Training Program (Certificate) _____

Psychotherapy Training Program (Certificate) _____

Taking Individual Seminars (without program enrollment) _____

Unsure – would like to discuss with an advisor _____

Options regarding payment plans or tuition assistance _____

Study Groups _____

 

 

PERSONAL PSYCHOANALYSIS or PSYCHOTHERAPY

Name of analyst/therapist: ______________________________ Degree ___

Dates in treatment ______________________________

Sessions per week _______________

 

 

____________________________________ __________

Signature                                                          Date

Must include:

PROFESSIONAL REFERENCES

List two individuals (other than your analyst or therapist, past or present) who are in a position to comment on your professional work and your suitability for training.

Please have each reference person cited complete Form A (below) and forward to TBIPS at the address indicated above.

Nature and Dates of  Professional Relationship, and

                Name                                    Address  

1.____________________________________________________________________________

2.____________________________________________________________________________

 

PERSONAL STATEMENT

Please submit a personal statement (4-7 pages) which would include how events and circumstances in your own life have contributed to your interest in psychoanalytic training.  Please include an assessment of your strengths and weaknesses along with a description of how you feel the training may assist with your professional goals, and any other reasons you may have for seeking training.

 

_______________________________                                             

            Signature

 

 

 

 

Please include the following with your completed application:

  • Current copy of your Curriculum Vitae
  • Copy of your state mental health services license and/or certifications, if clinical candidate
  • Copy of your current malpractice insurance certificate, if clinical candidate
  • Personal Statement (see description above)
  • Transcripts from undergraduate and graduate educational institutions
  • Professional references (Form A) should be forwarded directly from the recommender to TBIPS.

 

 

 

 

 

Send all application materials to: Tampa Bay Institute for Psychoanalytic Studies, Inc (T-BIPS)

13919 Carrollwood Village Run, Tampa, Florida 33618-2401

 

TBIPS does not discriminate on the basis of gender, race, creed, sexual orientation, physical disability, or national origin.

Form A – Reference

Tampa Bay Institute for Psychoanalytic Studies, Inc.

13919Carrollwood Village Run                                                                                             Tampa, Florida 33618  

Phone: (813) 908-5080                                                                               Website: tampapsychoanalytic.org

 

Form A – Reference

 

___________________________ has provided your name as a person who is familiar                 (Name of Applicant)                                                                                                                               

with their professional work.  Please write a brief evaluation of the applicant below, including comments about clinical skills, if applicable, and about personal integrity.

 

                                                                                          

 

 

 

 

 

 

 

 

 

 

Name of Reference (please print)     ____________________________________________________________

Address                          _______________________________________________________________________

                                       _______________________________________________________________________

 Phone   (____)___________________ Fax (___)_________________ Email ___________________________

 

Name and address of professional affiliation:

__________________________________________________________________________________________

__________________________________________________________________________________________ 

 

 

________________                                     _________________________

            Date                                                                       Signature of Reference

 

Please return completed form to:

Tampa Bay Institute for Psychoanalytic Studies, Inc

13919 Carrollwood Village Run

Tampa, Florida 33618

 

 

Orig. 09/05, rev. 6/10

 

 

 

 

 

 

 

 

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