Psychodynamic Psychotherapy Course Application

Name*
First Last
Date*
MM slash DD slash YYYY
Profession/Degree
Are you licensed in Florida?*
- Yes
- No
License number*
What is your professional status?*
Contact Information
Office Address
Street Address Address Line 2 City State ZIP Code
Office Phone
Cell Phone
Email Address*
Home Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Graduate Education
School 1
Degree 1
Dates 1
School 2
Degree 2
School 3
Degree 3
Dates 3
Residencies, Internships, Professional Training: (State type of program, institution, dates)
Other Professional Experience: (Clinical work, teaching, research, post-graduate courses)
Current Professional Activities:
Please upload a copy of your CV*
Accepted file types: txt, rtf, doc, docx, pdf, Max. file size: 12 MB.
Confirmation*
- I attest that, to the best of my knowledge, all of the above information is true, correct and not misleading.
Pay $600 tuition for one semester (opens in a new tab/window)