Application for Introductory-to-Intermediate 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