Clinical Consultants in Psychotherapy Application

Be prepared to submit the following:
Resume or C.V.
copy of Degree
copy of Clinical Licenses
copy of Malpractice Insurance
2 letters of reference
Name
Your answer
Clinical Degree
Your answer
Street Address
Your answer
City
Your answer
State/Territory
Your answer
Postal Code
Your answer
Telephone #
Your answer
email address
Your answer
Current professional position
Your answer
How many clinical hours per week do you see clients/patients?
Your answer
Number of years you have been licensed to practice.
Your answer
Malpractice Insurer
please list your malpractice insurance company including address and telephone (be prepared to submit a copy of your malpractice coverage)
Your answer
List the States in which you are licensed to practice
(be prepared to submit a copy of each active license you hold)
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
Please describe your clinical supervision experience (both within IPI and other institutions)
Name of supervisor, type of supervision (dynamic, cognitive behavioral, etc.), duration and frequency, and means of communication (phone or in-person, written process notes or recordings)
Your answer
Describe your personal experience with psychodynamic psychotherapy or psychoanalysis
(clinical orientation of therapist or analyst, treatment modality ( individual, couple, family), duration in years, and frequency.
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 describing your interest in clinical case consultation and your goals for the program
Your answer
I affirm 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 give permission for the Clinical Case Consultation Training program faculty to talk with my clinical supervisors or teachers about my clinical practice and skills.
Required
I affirm that I have access to and am able to use email, with encryption when necessary, internet, Pep Web and online video conferencing applications. All clinical material shared by email or internet will be encrypted.
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.
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