Application for Infant Observation Seminar
Address *
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Name *
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Email Address *
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Phone Number *
list home/office/cell
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Clinical Degree *
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From what university did you receive your clinical degree?
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In what year?
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Do you hold a state license to practice in a mental health field? *
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Are you currently practicing? *
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How many hours per week do you see patients/clients? *
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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. *
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Which IPI programs have you completed or attended? *
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Are you planning to take other courses at IPI, such as the Fellows Program; Child, Couple Family Program; the Psychodynamic Psychotherapy Certificate Program (PPCP); the analytic program (IIPT), etc? If so, when? *
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Have you had other experiences doing infant or young child observation? If so, please describe your experience: what institute or teacher did you study with, for how long, format of the class or seminar, etc. *
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Please list courses or seminars you have taken at other institutes since graduation from your clinical degree program and dates of those seminars. *
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Please describe your experience with clinical supervision: who supervised you, when, what kind of supervision and for how long. *
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Please state briefly why you are interested in taking Infant Observation at this time: *
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Observing an infant/parent is a required part of this seminar *
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