Application form_LQP

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.

List all colleges and universities attended. Please request that official transcript from the academic institution granting most recent degree be sent to admin@manhattanpsychoanalysis.com

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

References *

List the name and addresses of three (3) references. One reference should be in a position to evaluate your academic performance and two should be in a position to evaluate your professional experience. Do not include references from personal analysis. Three letters of recommendation should be emailed to admin@manhattanpsychoanalysis.com.

List the name(s) of your analyst(s) and/or therapist(s). Past or present. (If applicable) Please note that your therapist(s) will not be contacted.

Please include: Psychoanalytic Institute granting certificate to analyst. Dates of Treatment. Number of Sessions Per Week. Total Hours to Date.

You can upload this information here.

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Please tell us how you became interested in psychoanalysis and how you feel your prior training and experience may be relevant to your work as a psychoanalyst. We would also appreciate receiving 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 us in evaluating your application

You can upload this information here. (copy)

Click or drag a file to this area to upload.

How did you learn about the Manhattan Institute for Psychoanalysis?

Manhattan Institute is pleased to offer scholarships in each of our programs as well as designated scholarships for BIPOC candidates. Please check below if you would like to be considered for one of these scholarships. To advance the goal of increasing the participation of a diverse community in the Institute’s programs, we offer equity-based scholarships. Because funds are limited, please carefully consider your needs when applying.

E-Signature *

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

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