THE AMERICAN COLLEGE OF PSYCHOANALYSTS
An International Organization of Physician Psychoanalysts
APPLICATION FOR FELLOWS AND AFFILIATE FELLOWS
Please type and send entire application to Frances Bell, Executive Secretary, by email:
frda1@airmail.net or by regular mail: PO Box 570218, Dallas, TX, 75357-0218.
Name __________________________________________________________________
Work Address
________________________________________________________________________
________________________________________________________________________
Telephone Number ______________________ Cell phone________________________
E-mail __________________________________________________________________
Residence Address
________________________________________________________________________
________________________________________________________________________
Telephone Number ______________________ Cell phone________________________
E-mail __________________________________________________________________
Place of Birth
________________________________________________________________________
Current Nationality
________________________________________________________________________
Date of Birth
________________________________________________________________________
Name of Spouse or Domestic Partner
________________________________________________________________________
Topics of special interest in Psychiatry or in Psychoanalysis_____________________
Would you consider blogging about these topics? Y____ N____
Areas of teaching interest and experience____________________________________
_______________________________________________________________________
Would you consider teaching or mentoring psychiatric or psychoanalytic trainees or early
career psychiatrists in these areas? Y_____N_____
Please attach your CV. It should contain the following information:
Education: College, Medical School (Name of Institution, Date Graduated)
Graduate Education: Residencies, Fellowships, Other Graduate Work
(Name of Institution, Area of Study and Dates)
Psychoanalytic Training (Institute, Date of Graduation: (Adult, Child)
Current Memberships (Society/Institute: Member, Faculty, TA, SA)
Academic Appointments (Past and present): University, Title, Dates
Hospital Appointments (Past and present): Name of Institution, Dates
Licensure: (States and dates)
Board Certifications (Including Sub-Specialty Boards)
Other Professional Activities Private practice, areas of special interest,
subspecialties, consultant appointments, and positions held
Membership and Fellowship in Professional Organizations (include dates,
committee appointments, and offices held)
Community and Civic Activities
Armed Forces Services (Branch of Service, grade, dates)
Publications (Please send reprints of representative articles)
(If all of the above information is posted on your personal website, you may send
your website address in lieu of a CV)
Please also enclose your first year dues of $200 for Fellows and $100 for Affiliate
Fellows (psychiatrists in psychoanalytic training). After your application has been
received, a member of the American College of Psychoanalysts Membership
Committee will contact you.