Application for Admission to Certificate Program
Use this form to submit your initial application to the Admissions Committee. After you submit your initial information using this form, you will need to mail additional materials, noted in the checklist below, along with your application fee.



NOTICE OF NONDISCRIMINATORY POLICY FOR CANDIDATES

The Psychoanalytic Institute of Northern California admits candidates of any race, color, age, sexual orientation, or national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to candidates at the Institute. PINC does not discriminate on the basis of race, color, age, sexual orientation, or national and ethnic origin in admissions, in its educational policies or other Institute-administered programs.
Checklist of documentation to include with your application
1) Curriculum Vitae*

2) Copy of your current mental health license

3) Proof of liability insurance coverage

4) Statement of Interest*:

Please include an essay of 3-4 pages explaining why you have decided to apply for psychoanalytic training. Include those aspects of your experience you think will help us evaluate your application. You may use some or all of the following questions to organize your essay. These are included as suggestions only:

a) What do you see as your strengths as a therapist; as a potential analyst? What do you see as your shortcomings?

b) What experience in the last several years of your professional life has had a lasting impact on you?

c) Has there been some experience in your personal life that has affected your thinking about psychotherapy or the way you work?

d) In what ways do you think your work as a therapist has changed during the course of your career? What do you think have been the major influences bringing about the changes?


*May be sent via email to pincsf@gmail.com
Personal Information
Name *
Work Address *
Home Address *
Daytime Phone *
Evening Phone *
Email *
Degree *
Date Conferred *
License Number *
License Type *
Expiration Date *
Current Primary Professional Position *
Has your license ever been revoked or suspended? *
Required
Have you ever been involved in a professional malpractice suit? *
Required
Which program are you applying for? *
References
Please ask three individuals (supervisors, colleagues or others) who are familiar with your clinical work, other than your analyst/therapist, to submit a letter on your behalf discussing in detail whatever they consider relevant to your plans for psychoanalytic training to pincsf@gmail.com. The Admissions Committee may contact these individuals for additional information about your work.

Please list the individuals you have asked to submit letters on your behalf below.
First Reference
Ref 1 Name *
Ref 1 Work Phone *
Ref 1 Address *
Ref 1 Position *
Second Reference
Ref 2 Name *
Ref 2 Work Phone *
Ref 2 Address *
Ref 2 Position *
Third Reference
Ref 3 Name *
Ref 3 Work Phone *
Ref 3 Address *
Ref 3 Position *
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