Analytic Training Application

If you are returned to a blank form upon hitting "next," this indicates your form did not go through for processing -- please contact Randi Sarsfield at 314-361-7075 x 322 or email Randi Sarsfield.

I am applying for:*

Training in Adult Psychoanalysis
Training inChild and Adolescent Psychoanalysis - Traditional
Training in Child and Adolescent Psychoanalysis - Accelerated

I wish to be considered as a:*

Full Clinical Candidate
Part-time Clinical Candidate
Academic Scholar

Date

I. CONTACT INFORMATION

Name*

First Last

Middle

Degree

Preferred Name

How do you prefer to be addressed? Please indicate the title we should use in our formal correspondence with you:*

Dr.
Mr.
Ms.
Mx.

Other:

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone:

Telephone:

Email:*

Enter Email Confirm Email

Work:

Name of Institution:

Website

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone:

Email:

Preferred communications:

Home
Work

Date and Place of Birth:

Date

Place:

Citizenship/Status:

II. ACADEMIC BACKGOUND

(Scholar in Psychoanalysis applicants need only answer questions II.A and II.E in this section.)

Undergraduate and Graduate

A. Dates / Name of Institution / Location /Degree

Practicums, Internships and/or Residency:

B. Dates / Name of Institution / Responsibilities

Post Graduate Training:

C. Dates / Name of Institution / Description

Specialty Board Certification:

D. Dates / Board

Research Projects:

E. Project / Director / Address for Project Director

III. EMPLOYMENT EXPERIENCE (Scholar in Psychoanalysis applicants need only answer questions III. A. and III. B in this section.) A. Current Employment:

Profession:

Place of Employment:

Position:

Length of Employment:

Description of what you do:

B. Previous Employment:

Dates / Position & Experience

C. Supervision, Consultation, Practicum or Volunteer Experience (that is relevant to this application):

Dates / Name of Institution / Responsibilities

IV. OTHER INFORMATION (If Applicable) (Scholar in Psychoanalysis applicants need only answer question IV. A in this section.) A. Awards, honors, publications or other demonstrations of merit (list):

Dates / Description

B. Personal therapy or Analysis: (The Institute totally respects the confidentiality of the therapist/patient relationship and will not in any way attempt to contact the therapist.)

Name of therapist

Frequency of Sessions

Dates From To

Name of therapist

Frequency of Sessions

Dates From To

V. REFERENCES (All applicants) Please list two or more references. Your submission of this application form indicates that you give your permission for us to contact the names below.

Reference #1 Name / Address / Telephone / E-mail

Reference #2 Name / Address / Telephone / E-mail

Reference #3 Name / Address / Telephone / E-mail

VI. ADDITIONAL QUESTIONS
Please e-mail to Randi Sarsfield, Program & Services Coordinator, at office@stlpi.org your answers to the following questions.

A. For full and part time clinical candidate applicants in Child or Adult Program:

1. What are your goals in undertaking this program?
2. How would this program fit in with your professional objectives/plans over the next five years?
3. Autobiography: Please enclose a personal and professional history (not to exceed ten pages double spaced) describing the evolution of your interest in psychoanalysis.

B. For Child and Adolescent full and part time clinical candidate applicants:

1. Please describe your experience with children/adolescents.
C. For Scholar in Psychoanalysis applicants:

1. Please enclose a description of your academic/research interests and how you plan to use psychoanalysis in them. (A maximum of five pages double spaced, please).
VII. ADMINISTRATIVE INFORMATION

(All applicants are to complete this section.)

How did you hear about or find this program?

A. Other Psychoanalytic training applications: If you have applied for psychoanalytic training elsewhere, please list the Institute(s), date(s), and outcome(s):

May we contact these Institutes?
Yes
No

B. Do you anticipate needing to use video conferencing to attend classes/supervision?
Yes
No

If yes to needing videoconferencing, please explain why.

C. Describe any special circumstances (financial concerns, scheduling or personal issues) that may affect or complicate your participation in this program:

Will a third party be paying any or all of your tuition?
Yes
No

Please explain:

D. Do you wish to apply for financial aid?
Yes
No

For Scholarship Consideration
I am submitting my course application along with a request to be considered for a need-based scholarship.
I will be mailing a copy of my tax return, completed scholarship application, and financial need statement to: Randi Sarsfield, St. Louis Psychoanalytic Institute, 7700 Clayton Road, Suite 200, St. Louis, MO 63117, or drop them off at our offices.
I understand that if I apply for financial aid, my application, tax return, statement of financial need and references will be assessed by the Financial Aid Committee.

Completed scholarship applications are due before April 15th. To be considered "complete" the office must receive your application form (either electronically or by mail), and a hard copy of your current tax return, along with a brief statement of your financial need.

CLICK HERE FOR NEED BASED SCHOLARSHIP APPLICATION

CLICK HERE FOR MERIT SCHOLARSHIP APPLICATION

VIII. SUBMISSION AGREEMENT
(All applicants are to complete this section.)

For All Programs:
I understand that my application and progress within this program will be subject to assessment by the instructors in the program and agree to abide by this assessment.
I have requested a transcript be sent to the St. Louis Psychoanalytic Institute from

A transcript will be sent from:

SIGNATURE

DATE

There is a $300 application fee due at the time you submit your written application. The application fee covers the processing of your application along with your applicant interviews which will be scheduled for you in the future.

Completed applications may be printed and mailed with your application fee to: Randi Sarsfield, St. Louis Psychoanalytic Institute, 7700 Clayton Road, Suite 200, St. Louis, MO 63117 or completed and submitted online.
The application fee may be submitted by check (payable to the St. Louis Psychoanalytic Institute) or submitted online.

Please indicate your form of payment:
My check is enclosed
I am processing an on-line payment

Analytic Training Application
Price: $300.00

Total
$0.00

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