Psychodynamic Psychotherapy Program
Application for the 2 year program

Be prepared to submit the following:
Resume or C.V.
copy of Degree
copy of Clinical Licenses
copy of Malpractice Insurance

Name
Your answer
Degree/Title
Your answer
Street Address
Your answer
City
Your answer
State/Territory
Your answer
Postal Code
Your answer
Telephone #
Your answer
email address
Your answer
Malpractice Insurer
please list your malpractice insurance company (be prepared to submit a copy of your malpractice coverage)
Your answer
List the States in which you are licensed to practice
Your answer
Psychodynamic/Object Relations Training (or equivalent)
(Please give title of course, institution where training occurred, date completed and attach copy of certificate of completion. The PPP Faculty will review non-object relations programs or programs offered by other institutions and reserves the right to require additional course work):
Your answer
Current Professional Position
Your answer
How long have you worked in your clinical field?
Your answer
How many hours/week do you see clients/patients?
Your answer
Previous Supervision Experience (both within IPI and other institutions)
Name of supervisor, type of supervision (dynamic, cognitive behavioral, etc.), duration and frequency
Your answer
Describe your personal experience with psychodynamic psychotherapy or psychoanalysis
Clinical specialty of therapist or analyst, “type” of treatment, duration in years, frequency (# of times per week)
Your answer
Please provide the names and contact information for two teachers or supervisors who will submit letters of recommendation on your behalf to IPI c/o Ms. Anna Innes:
Your answer
Please write a brief statement on why you would like to take training in the PPP.
Your answer
I would like to apply to the...
I certify that there are no past or pending findings of unethical or unprofessional conduct against me or past or pending actions against my clinical license. For the duration of my involvement with IPI, I agree that I will notify IPI if my situation changes in regard to ethical and licensing complaints.
Required
The International Psychotherapy Institute (IPI) is approved by the American Psychological Association to sponsor continuing education for psychologists. IPI maintains responsibility for the program and its content. IPI is an NBCC Approved Continuing Education Provider (ACEP) and may offer NBCC approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program IPI is a California Board of Behavioral Sciences approved continuing education provider for MFCC and LCSW licensure (approval #PCE 1508). The International Psychotherapy Institute is an approved sponsor of the Maryland Board of Social Work Examiners for continuing education credits for licensed social workers in Maryland. The International Psychotherapy Institute is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers.
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