TAMPA BAY

INSTITUTE FOR PSYCHOANALYTIC STUDIES

14043 Dale Mabry Hwy. N., Tampa, Florida 33618

Phone: (813)908 – 5080 Email: TBIPStraining@gmail.com

Website: www.tbpsychoanalytic.org/tbips.html

TBIPS

Application for Training

Name (print) _________________________________________________________________

Address Home ____________________________________________________________

_________________________________________________________________

Business __________________________________________________________

_________________________________________________________________

Phone Home (___)____________________ Business (____) _____________________

Email _____________________________ Fax (____)__________________________

Birthdate __________________ Age _____ Social Security Number _________________

ACADEMIC BACKGROUND

Previous psychoanalytically oriented studies, if any:

Institution___________________________________Dates of Attendance__________________

Courses completed (list courses or attach transcript)

PROFESSIONAL BACKGROUND

1. Licensure and/or Certifications (Indicate states and type):

2. Professional Affiliations

3. If employed in mental health field, list the name of your agency or employer and provide a brief description of your work.

4. If in private practice, describe the nature of your practice including the populations served, treatment modalities, and length of time in practice.

5. Describe any additional work experience or specific skills (including areas not directly related

to psychotherapy or mental health):

6. Briefly describe your interest in psychoanalytic practice and thought

I am interested in: (please check all that apply)

• Psychoanalytic Training Program (Certificate) _____

• Psychotherapy Training Program (Certificate) _____

• Taking Individual Seminars (without program enrollment) _____

• Unsure – would like to discuss with an advisor _____

• Options regarding payment plans or tuition assistance _____

• Study Groups _____

PERSONAL PSYCHOANALYSIS or PSYCHOTHERAPY

Name of analyst/therapist: ______________________________ Degree _________________

Dates in treatment ______________________________ Sessions per week _______________

_______________________________ _____________________________

Signature Date

Please include the following with your completed application:

• Current copy of your Curriculum Vitae

• Copy of your FL state mental health services license and/or certifications

• Copy of your current malpractice insurance certificate

Send all application materials to: Tampa Bay Institute for Psychoanalytic Studies

14043 Dale Mabry Hwy N. Tampa, Florida 33618

TBIPS does not discriminate on the basis of gender, race, creed, sexual orientation, physical disability, or national origin.