TAMPA BAY INSTITUTE FOR PSYCHOANALYTIC STUDIES
13919 Carrollwood Village Run,
Tampa, Florida 33618
Phone: (813)908 – 5080 end_of_the_skype_highlighting Email: firstname.lastname@example.org begin_of_the_skype_highlighting
Application for Training
Name (print) _________________________________________________________________
Address Home ____________________________________________________________
Phone Home (___)____________________ Business (____) _____________________
Email _____________________________ Fax (____)__________________________
Birthdate __________________ Age _____ Social Security Number _________________
Previous psychoanalytically oriented studies, if any:
Institution___________________________________Dates of Attendance__________________
Courses completed (list courses or attach transcript)
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 _______________
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
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.
Please include the following with your completed application:
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) ____________________________________________________________
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