Telephone: (415) 563-3366 www.sf-cp.org Psychoanalytic Psychotherapy Training Program Electronic Application for Admission Submitting this application Applications will be accepted beginning on January 1, 2016. Applications will not be considered to have been submitted until the primary application and all supporting documents have been received. All applicants who submit completed applications by April 1 will be guaranteed consideration for matriculation in September 2016. Those whose applications are completed after April 1 will be considered only after earlier applicants have been offered admission. In recent years, there have been more applicants than positions. Qualified applicants who are not offered 2016 admission may be offered a position on the 2016 waiting list, as well as guaranteed matriculation in 2017 should 2016 matriculation prove impossible. How to apply Please complete this entire form in Microsoft Word and email it to email@example.com. Answers should be typed into the greyed boxes. Please note that this form will expand to accommodate answers of any length. In addition to this form, we request supporting documents, which are further described below. If you have any difficulties downloading this application, please contact Laura Ingram at (415) 563-5815 or email her at firstname.lastname@example.org. How to Pay the Application Fee For your application to be considered complete, your $50 application fee must be received at SFCP along with your application. You may pay by (a) adding your credit card information below, (b) sending a check to SFCP, 444 Natoma Street, San Francisco, CA 94103, or (c) calling in credit card information to Laura Ingram at 415-563-5815. All applications and application fees must be received by April 1 to be considered for Fall 2016. For applicants who are offered admission to PPTP in Fall 2016, the application fee will be non-refundable and will be applied to 2016-2017 tuition. Applicants who are not offered admission for fall 2016 will receive a refund of the application fee. For questions regarding the application process in general, please contact Genie Dvorak, Psy.D. at (415) 249-9184 or Nancy Beckman, Ph.D. at (415) 346-9446. For other program questions, please contact Beth Steinberg, Ph.D. at (415) 441-5302 or Adam Goldyne, M.D. at (415) 826-9639. Please contact Laura Ingram at (415) 563-5815 if you do not receive acknowledgement that we have received your application within two weeks of submission. PERSONAL INFORMATION Name: Degree: Date of Application: Office address: Home Address: Preferred telephone: Home Work Cell Second telephone: Home Work Cell Third telephone: Home Work Cell Preferred email: Sex: Date of birth: Age: Social Security #: LICENSURE If you are licensed, please fill out this section. Professional License Number: Professional Liability Insurance: Board Certification Certifying board: (if applicable): Date of certification: State: SUPERVISOR’S LICENSE AND LIABILITY INSURANCE If you are working under a supervisor’s license and professional liability insurance, please fill out this section. Note: If you are neither licensed and insured, nor working under the professional liability insurance of a supervisor or organization, please apply to Foundations of Psychoanalytic Psychotherapy rather than to PPTP. Further questions about eligibility may be directed to Genie Dvorak, Psy.D. at (415) 249-9184 or Nancy Beckman, Ph.D. at (415) 346-9446. Name of supervisor: Supervisor’s Professional License Number: State: Supervisor’s Professional Liability Insurance: EDUCATION AND TRAINING Please include all undergraduate and graduate experience Institution Dates attended Degree Year RESIDENCIES AND TRAINING PLACEMENTS If you are a psychiatrist, please list your residency. Other applicants should list psychological assistantships and other pre- and post- degree training placements completed within the last seven years. Institution Position Dates RELEVANT WORK EXPERIENCE Briefly describe clinical work experience. Include years in practice, clinical settings (e.g.: agency, hospital, private practice, etc.), average patient hours per week, nature of practice: frequency, type of patient, etc. (1) Work setting: Dates: Position/Description: (2) Work setting: Dates: Position/Description: (3) Work setting: Dates: Position/Description: (4) Work setting: Dates: Position/Description: (5) Work setting: Position/Description: TEACHING, RESEARCH, PUBLICATION, SUPERVISORY EXPERIENCE If applicable, briefly describe. Dates: OTHER RELATED PROFESSIONAL EXPERIENCES List classes, seminars, consultation, and other educational experiences in which you have participated. Please specify if any of these have been of a psychoanalytic nature. PROFESSIONAL MEMBERSHIPS PSYCHOANALYSIS OR PSYCHOTHERAPY If you are comfortable doing so, please provide additional information about your past and current treatments below. Although we are interested in this information, be assured that personal treatment is not a prerequisite for taking the PPTP. Have you been in psychoanalysis or psychotherapy? Type of treatment Note: You need not provide names of psychotherapists or psychoanalysts you have seen. Session frequency Year treatment Year Treatment began ended (1) (2) (3) PERSONAL STATEMENT In the space below, please tell us about yourself in any way that you think would be helpful, including your reasons for and what you hope to achieve in undertaking a program in psychoanalytic psychotherapy. (Please limit remarks to two pages.) LETTER OF REFERENCE Someone familiar with your training or clinical work should send us a letter of reference directly, either electronically or by U.S. Mail. Please list your reference below, including the context in which he or she knows your work. (1) ADDITIONAL INFORMATION In this optional section, please add anything else you would like the Admissions Committee to know in considering your application. DECLARATION OF LEGAL AND ETHICAL STANDING Has there ever been a complaint of ethical misconduct or unprofessional conduct brought against you that resulted in a determination of misconduct and ensuing sanction? YES NO Has there ever been a complaint or investigation of you concerning impairment? YES NO Have you ever been suspended from teaching or administrative functions in relation to a professional ethics or impairment issue? YES NO Has your membership in a professional or educational organization ever been suspended or terminated in relation to a professional ethics or impairment issue? YES NO Has there ever been a finding against you by a professional licensing board? YES NO If your answer to any of these questions is “Yes,” please explain at greater length: INTERVIEW Once your complete application and letter of reference have been received, an interviewer will call you to set up a meeting. Part of the interview will be a dialogue about your interest in psychoanalytic psychotherapy, about how you see it fitting into your professional life, and about whether our program is the right fit for you. In addition, you should be prepared to discuss a recent session with a patient. You may choose to bring notes, but they are not required. The main aim of this discussion will be for us to get a sense of how you are thinking about clinical work at this point in your career and to begin to offer you a sense of our approach to clinical thinking. One interview may not afford sufficient time for a complete discussion. If this is the case, your interviewer will invite you to meet for a second time. SIGNATURE By entering your name and the date below, you acknowledge that the information in above sections is true and accurate to the best of your knowledge. Electronic submission of this form by email is equivalent to your handwritten signature. Signature: Date: SFCP COMMUNITY MEMBERSHIP ENROLLMENT Enrollment in the Psychoanalytic Psychotherapy Training Program includes Community Membership in SFCP. (See SFCP website for community membership benefits.) Community members are included in the printed and on-line member roster for SFCP. Please fill out the following information, so that this page may be forwarded directly to Community Membership enrollment: Name: Address: Work Profession/Degree: Telephone: Fax: Email: Once enrolled in PPTP, your member information will be included in the SFCP roster and SFCP website unless you check the space below: DO NOT include my information in the printed roster DO NOT include my information in the on-line roster Other comments: APPLICATION INSTRUCTIONS AND CHECKLIST To complete this application, the following should be sent to SFCP: This entire file, including this checklist and the ‘SFCP Community Membership Enrollment Form’ above, sent as an email attachment submitted Letter of reference requested A curriculum vitae (if you have one) submitted N/A A copy of your California professional license (if applicable) submitted N/A A copy of your professional liability insurance policy (if self-insured) submitted N/A A copy of a supervisor’s professional liability insurance policy (if you work under a supervisor and covered by that supervisor’s liability insurance) submitted N/A $ 50 application fee (via credit card or check). All applications and fees must be received at SFCP by April 1. Please check one of the following: Please charge my credit card for the $ 50 application fee as below: Credit Card Type: Visa MasterCard Credit Card Number: Expiration Date: / (mm/yy) Billing Zip-code: I have paid the $ 50 application fee by calling in my credit card information to Laura Ingram at the SFCP Office at (415) 563-5815 on date. I have paid the $ 50 application fee by mailing a check to the SFCP Office (444 Natoma Street, San Francisco, CA 94103) on date. We would like to make sure that, as you apply, you have accurate expectations regarding PPTP tuition and when it is due. Please check the box below to indicate that you have read and understood these policies. The total yearly tuition for PPTP/Foundations is $ 2,175. We will make every effort to notify you by early June regarding admission. At that time, your $ 50 application fee will be applied to your tuition, and we will ask you send a non-refundable deposit of $ 675 by July 1 to confirm your spot in the program for Fall 2016. There are two options for paying the remaining $ 1,450: (1) a lump sum of $1450 paid by August 15 or (2) four installments of $ 362.50, with the first payment due August 15, with each subsequent payment due two weeks prior to the beginning of each quarter, and with a one- time $ 50 installment fee due August 15 with your first payment. Supervision fees are separate from tuition and are arranged individually between supervisor and supervisee. If you have concerns about this tuition payment schedule or other financial aspects of the program, please contact us to discuss possibilities for alternative arrangements. I Understand If possible, email supporting documents that have been scanned or obtained in electronic form. Any documents that cannot be submitted electronically may be mailed to: San Francisco Center for Psychoanalysis 444 Natoma Street San Francisco, CA 94103 ATTN: PPTP If you do not receive acknowledgment that we have received your application within two weeks of submission, please contact Laura Ingram at (415) 563-5815 or at email@example.com.