APP Application « Saint Louis Psychoanalytic Institute: Working to Promote Mental Health Through Psychoanalytic Education, Inquiry, and Practice

Please note: for all attachments requested for this application, please attach them in a separate e-mail to: Bobbie Land. If you are returned to a blank form upon hitting "submit," this indicates your form did not go through for processing -- please contact Bobbie Land at 314-361-7075 x 319 or e-mail Bobbie Land.

I am applying for*

Advanced Psychodynamic Psychotherapy Program (APP)

Date:*

I. CONTACT INFORMATION

Last Name:*

First Name:*

Middle:

Degree:*

Preferred Name:

Gender:*

Male
Female

Home Address:

City, State, Zip:

Telephone:*

Cell Phone

Email:*

Enter Email Confirm Email

Work:

Name of Institution:

Website:

City/State/Zip

Work Telephone:

Work E-mail:

Preferred communications:

Date of Birth:

Place of Birth:

Citizenship/Status:

II. ACADEMIC BACKGROUND

Name of Institution: Please add Dates, Location, Major and Degree

Additional Degree:

Special interests during your education:

III. EMPLOYMENT EXPERIENCE

Current Employment - Profession:

Place of Employment:

Position:

Length of Employment:

Description of what you do:

Previous Employment: Dates, Position and Experience

Additional Previous Employment: Dates, Position and Experience

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

IV. OTHER INFORMATION (If Applicable)

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:

V. REFERENCES 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 answer the following questions and e-mail your answers to Bobbie Land, Program & Services Coordinator. We ask that you limit your responses to a total of three typed pages.
All Applicants:
1. What are your goals in undertaking this program?
2. Briefly describe an incident in your work in which you were pleased with your efforts.
3. Briefly describe an incident in your current work in which you feel you did not do as well as you would have liked. What additional information or guidance would have helped you?
4. How would this program fit in with your professional objectives/plans over the next five years?
5. Describe your experience doing psychotherapy or counseling.

VII. ADMINISTRATIVE INFORMATION

A. Do you intend to use this program for degree credit at an academic institution? Yes/No If yes, please describe your arrangement.

B. Do you anticipate needing to use video conferencing to attend classes/supervision?*

Yes
No

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

Do you wish to apply for financial aid?*

Yes
No

Please explain:

If yes, are you eligible for the Silk Foundation Scholarship?

Yes
No

Silk Foundation Scholarship
The Silk Scholarship, established in 2010, supports Jewish students and other talented professionals dedication to working in the Jewish Community. Qualified students who lack the financial resources to advance their education with the St. Louis Psychoanalytic Institute may apply for a Silk Scholarship.

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.

For Scholarship Consideration

I am submitting my course application along with a completed scholarship application to be considered for scholarships.
I will be mailing a copy of my tax return and financial need statement to: Bobbie Land, St. Louis Psychoanalytic Institute, 8820 Ladue Road, 3rd Floor, St. Louis, MO 63124, 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.

CLICK HERE FOR NEED-BASED SCHOLARSHIP APPLICATION
CLICK HERE FOR MERIT SCHOLARSHIP APPLICATION

VIII. SUBMISSION AGREEMENT

*

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 also understand that this program is not being represented as training for practice in Psychoanalysis but as augmentation of existing theoretical knowledge and clinical skills in advanced psychoanalytically-oriented psychotherapy, for which specific recognition will be given upon graduation.

SIGNATURE _______________________________________________________________________ DATE__________________________________
There is a $75 application fee due at the time you submit your written application. The application fee covers the processing of your application along with your applicant interview which will be scheduled for you in the near future.

Completed applications may be mailed with your application fee to: Bobbie Land, St. Louis Psychoanalytic Institute, 8820 Ladue Road, 3rd floor, St. Louis, MO 63124. Please enclose a check payable to the St. Louis Psychoanalytic Institute.

Please indicate your form of payment below:*

I will mail in my payment.
I am processing an on-line payment.

Reminder: For your application to be considered for financial aid, your completed application form, tax return, brief statement of financial need and references must be received by April 15th. Applications received later than April 15th will be considered by the Financial Aid Committee only if funds are available.

Application Fee. Note that the Tuition price is for ONE YEAR of the TWO-YEAR program. Tuition will be billed twice a year.

Price: $75.00 Quantity:

Total

$0.00

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