More Information Interest Form

This Interest Form may be used to request information about our programs. Please fill in your information, and click the "Submit" button. You will receive a follow-up email or telephone call from a point of contact if the form worked properly and the information was complete. If you do not hear from us within five business days, please call us at 314-361-7075 x319 or email recruitment@stlpi.org. Please note that this Interest Form is NOT an application for the selected program(s). This form provides us with your contact information so that we can follow up with you, or let you know when our next application process begins or meeting happens.

First Name*

Last Name*

Email*

Enter Email Confirm Email

Phone*

Address

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

Language Fluency

Best time to contact you:

Weekdays
Weekends
Mornings
Afternoons
Evenings
Anytime

Preferred contact method:

Email
Phone
Mail

Program(s) Interested in (check all that apply)*

Have you already completed any appropriate online applications?*

Yes
No

Which area (s) of mental health interest you the most?*

Are you currently working on a Graduate Degree?*

Yes
No

If yes, please provide some background:

Please list all of your Undergraduate and Graduate Degrees:*

Are you a clinically licensed or provisionally licensed practitioner?*

Yes
No

Did you have any courses on the psychodynamic/psychoanalytic approach as an entire course, while working on your graduate studies?*

Yes
No

If yes, how many? Please list the Course Titles and Dates below:

Did you have supervision at any time during your training, with a supervisor that used the psychodynamic/psychoanalytic approach?*

Yes
No

If yes, what were the dates, both starting and ending of your supervision?

Could you potentially attend classes during the day, approximately 10 a.m. through 4 p.m. CST on Fridays from Sept. through April?*

Yes
No

Could you potentially attend classes during the evenings, approximately 6 p.m. through 9 p.m. CST on Mondays from Sept. through April?*

Yes
No

Do you potentially have the flexibility to attend two group supervisions during the week?*

Yes
No

Questions? If there are any specific questions that you have, please enter those here:

How did you hear about the Institute?*

Email
Flyer
Word of mouth
Other

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