Application for Advanced Clinical Consulting Groups

Personal Information:*

First Last

Title/Degree

Office Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Email*

Education and Training: Graduate School/Medical School

Year Graduated

Residency/Clinical Internship

Year Completed

License Number and State

Professional Information: Place(s) of Practice (Private Practice, Hospital, University, Etc)

Number of hours (approximately) of Outpatient Individual Therapy Post-Licensing (We require a minimum of 5000 clinical hours. That is roughly 20 clinical hours per week, for 5 years):

Years in Practice as a Licensed Clinician

Didactic Training Experiences in Psychoanalytic or Psychodynamic Theory or Technique, i.e. training programs, seminars, workshops, or conferencec:

Ethical Disclaimer

Ethical Disclaimer: Have there ever been any findings of unethical or unprofessional conduct?*

No
Yes

Please explain.*

Are there any current or pending charges or allegations of unethical or unprofessional conduct?*

No
Yes

Please explain.*

Please upload a copy of your CV*

Accepted file types: txt, rtf, doc, docx, pdf, Max. file size: 12 MB.

Explanation of findings or unethical or unprofessional conduct:

Explanation of current or pending charges or allegations of unethical or unprofessional conduct:

I certify that the above statements are true.*

Yes