Application Form for Training in Child Psychotherapy at IPI
Name (Degree) *
Your answer
Address *
Your answer
email *
Your answer
phone *
Your answer
Affiliation with IPI *
Your answer
Date of graduation from IPI Core program *
Your answer
If you have not attended the IPI Core program, please describe equivalent training in Object Relations Theory and Practice:
Your answer
Date of graduation from PCPP (if applicable)
Your answer
Previous course/training in work with children and adolescents *
Your answer
Previous internships/student placements working with children and adolescents *
Your answer
Previous supervision in work with children and adolescents *
(frequency, hours, and name of supervisor)
Your answer
Current and previous experience in work with children and adolescents *
Classroom teaching, nursing, raising children, working in a child clinic, child care, diagnostic evaluations, consultation-liaison, child psychotherapy, family therapy, etc
Your answer
Authored publications on psychotherapy with children
Your answer
Have you completed Infant Observation? *
If you answered yes to completing Infant Observation,
# of Hours and Name of seminar leader
Your answer
Why I want to do child psychotherapy training *
Your answer
Please verify and send the following items to IPI *
send by email: info@theipi.org, fax: 301-951-6335, or mail 6612 Kennedy Drive, Chevy Chase, MD 20815
Required
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
I will send three letters of reference, at least one of them known to IPI (please identify your 3 references below) *
letters can be sent by email: info@theipi.org, fax: 301-951-6335, or mail 6612 Kennedy Drive, Chevy Chase, MD 20815
Your answer
Please verify the following *
Required
I have completed the hours of personal psychotherapy at ___times a week frequency for __ months   *
Your answer
You may contact my therapist to confirm attendance only (IPI is a non-reporting institute) *
list therapist name and phone number
Your answer
I prefer to pay tuition by *
I want to negotiate an installment payment plan, and agree payment will be complete before graduation *
I certify that the information I have submitted and written on this application is accurate to the best of my knowledge. I authorize the IPI Child Training Program and its Admissions Committee members to contact the references I have given concerning my application *
Type your name to confirm
Your answer
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