Application form_OYP

Date *

Name *

First

Last

Your preferred pronouns

Email *

Phone

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Institution awarding professional degree. Type of Degree. Date of Degree.

Are You licensed? License number.

Do you have Malpractice Insurance?

If yes, carrier and amount.

1. Education. List all colleges and universities attended or see below to upload documents. *

From: (Mo/Yr) To: (Mo/Yr) Name & Address of Institution Major Degree Received Date (Mo/Yr)

You can upload this information here.

Click or drag a file to this area to upload.

2. Experience *

Beginning with the current year, list your professional experience, including private practice. Include the name and address of each employer, the name of each supervisor, your position and responsibilities. Unless you specifically request us not to, we assume that you grant is permission to communicate with any of your supervisors.

3. References *

List the name and addresses of two (2) references. whom you will ask to submit a letter of recommendation to admin@manhattanpsychoanalysis.com

You can upload this information here.

Click or drag a file to this area to upload.

4. Please tell us how you became interested in psychoanalysis/psychoanalytic psychotherapy and how you feel the training may be relevant to your clinical work? We also welcome any additional information that you may consider helpful, e.g., your expectations of our training program, special areas of interest, and any aspects of your personal background that may be helpful to use in evaluating your application.

You can upload this information here.

Click or drag a file to this area to upload.

How did you learn about the Manhattan Institute for Psychoanalysis?

In alignment with The Manhattan Institute for Psychoanalysis One Year Program: Psychoanalysis and the Sociopolitical World's commitment to the inclusion of BIPOC subjectivity we have adopted an equity based scholarship for all BIPOC candidates that are in need.

E-Signature *

You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name

12352