APPLICATION FOR ADMISSION TO PROGRAM IN PSYCHOANALYSIS
Personal
Social Security #_______________________________(you may leave blank)
Last Name______________________________First_________________Middle__________
Address_________________________________________________________________________________________________________________________________________
Home Telephone_____________Cell Phone______________Work Phone____________
Fax_________________________Email_______________________________________
Date of Birth___________Marital Status: Single________;Married_________:Other___
If married, spouse's full name________________________________________________
Citizen
Please attach firmly a
passport photo to the reverse page)
Academic
Undergraduate
College_____________________________________________________
Location______________________Degree_____Field____________________Date___
Graduate University______________________________________________________
Location______________________Degree_____Field____________________ Date___
Graduate University_______________________________________________________
Location______________________Degree_____Field_____________________Date___
Information
Systems & Computer Applications. If you have taken this course or
the equivalent, please provide documentation.
Graduate transcript(s) must be sent directly from
Registrar to the Admissions Officer of ISMHP.
Work Experience
List all employment of the last ten years: name,location; dates; duties; reason for leaving:
1.______________________________________________________________________________________________________________________________________________
2.______________________________________________________________________________________________________________________________________________
3.______________________________________________________________________
________________________________________________________________________
4.______________________________________________________________________________________________________________________________________________
5.______________________________________________________________________________________________________________________________________________
Recommendations
Three letters of recommendation are required. These should
only be from graduate professors (at
least one) and supervisors (at least
one) of your recent work place(s). The letter should include an assessment
of your work, ethics and that you are recommended (to the best knowledge of the
one writing) for psychoanalytic training and the treatment of patients. These
letters are to be sent directly to the Admissions Officer of ISMHP.
Have you ever been found guilty, or pleaded guilty, no content, or nolo contendere to a crime (felony or misdemeanor) in any court? Yes _____ No ____.
Are criminal charges pending against you in any court? Yes ____ No ____.
Has any licensing or disciplinary authority refused to issue or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? Yes ____No_____
Are charges pending against you in any jurisdiction for any sort of professional misconduct? Yes ____No ____.
Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever voluntarily resigned or withdrawn from such
association to avoid imposition of such measures? Yes ___No ___.
Note: If you answer
"Yes" to any of the above questions , submit
a letter giving a complete detailed explanation.
It is understood that if you are accepted into the ISMHP Psychoanalytic Program, you are required, at your own expense, to carry maximum malpractice insurance which covers specifically ISMHP and any ISMHP related agencies in which your work is carried out.
I hereby certify that
the information given in this application is accurate and complete to the best
of my knowledge. If, I am accepted as a student, I agree to abide by the
policies, philosophy of conduct, and expectations of
Date:_____________________Signature_____________________________________
NOTARY
State of
__________________________County of ___________________________
On the ____day of
_________ in the year ______, before me, the undersigned, personally appeared
__________________________________, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is
subscribed to this application and acknowledged to me that he / she executed
the application and swore that the statements made by him / her in the
application and all supporting materials are true, complete and correct.
Notary Public's
Signature________________________________________________
Notary ID number
__________________
Expiration Date:___________________
Month Day
Year Notary Stamp