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      THE METROPOLITAN INSTITUTE
    FOR TRAINING IN PSYCHOANALYTIC PSYCHOTHERAPY

 

Date _____________________

Name __________________________________________________________________

Address _______________________________________________________________

        _______________________________________________________________

Telephone ______________________ Telephone ____________________________
Home						 Work

Email_________________________ Fax_______________________

Discipline _____________________Graduate Degree ___________________________

Year Obtained________________________

School __________________________________________

Undergraduate Degree ________________Year Obtained ________________

School______________________________________


N.Y. State Certification or License No. _______________________________

Please check one:

_________ Full-time Adult program  

_________ Part-time Adult program

_________ Non-matriculated coursework: Adult Program

_________ Clinical Training in Child and Adolescent Psychotherapy

_________ Non-matriculated coursework: Child and Adolescent Program

Please check one:

I am applying for the Fall semester _____ Spring semester _____


Current Employment:

Position _____________________________________________________________

Name of Employer _____________________________________________________

Address ______________________________________________________________


Personal Psychotherapy/Psychoanalysis:

(List current or most recent therapy)

Name of Therapist/Analyst ____________________________________________

Therapist's Affiliation(s) if known: _______________________________________

____________________________________________________________________

Dates of Treatment: from ____________________ to _____________________

Frequency of Sessions ________________________________________________


Please list all previous personal therapy/analysis:


Name of Therapist/Analyst ____________________________________________

Therapist's Affiliation(s) if known: ______________________________________

___________________________________________________________________


Dates of Treatment: from ____________________ to _____________________

Frequency of Sessions ________________________________________________


Name of Therapist/Analyst ____________________________________________

Therapist's Affiliation(s) if known: _________________________________

______________________________________________________________________

Dates of Treatment: from ____________________ to _____________________

Frequency of Sessions ________________________________________________


How did you learn about Metropolitan Institute?

_____________________________________________________________________

PLEASE INCLUDE:
1) MITPP Application for Training
2) $40.00 non-refundable fee
3) An up-to-date curriculum vita (resume)

Send to:
Joyce A. Lerner, CSW, Director
MITPP
160 West 86th Street
New York, New York 10024

4) Two letters of reference on letterhead from current or former supervisors, teachers, administrators or other such professionals who are familiar with your work must be forwarded to MITPP by the writer on your behalf. 

Painting-"The Law of One" by Ariyon Deborah Salt www.ariyon.com