Apply - International Psychotherapy Institute

International Psychotherapy Institute Program Application

Select a programPlease choose the program for which you are applying

Which level are you applying for

Please select whether you are applying to the academic or clinical track.

Please select whether you are applying to the child psychotherapy or child psychoanalysis track.

Personal Information

First Name *

Last Name *

Preferred Pronouns

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Training

Professional Discipline *

Degree or Credentials *

Which of the following courses have you completed at the IPI?

Please list other courses you have taken.

Basic Psychotherapy TrainingList program(s) and Date(s) completed

Advanced Psychotherapy Training taken at IPIList program(s) and Date(s) completed

Advanced Psychotherapy OR Analytic Training taken at other InstitutesList Institute name, name of course(s), number of hours, and date(s) completed

Postgraduate Training

Please give title of course, number of clock hours, institution where training occurred, date completed and upload a copy of certificate of completion if possible.

Object Relations Training (or equivalent)

Please give title of course, number of clock hours, institution where training occurred, date completed and upload a copy of certificate of completion if possible.

Training and experience with children

List any coursework you have completed for working with children and adolescents.

List any internships or student placements working with children/adolescents:

List any current and prior experience in work with children/adolescents

(classroom teaching, nursing, raising children, child care, diagnostic evaluations, child psychotherapy, family therapy, etc.)

List any psychotherapy supervision working with children/adolescents

(frequency, hours, name of supervisor)

List any authored publications on psychotherapy with children

List any other experience you have had in infant/young child observation.

(institution name/course, length of seminar, frequency of observation, etc.)

Professional Practice

Current professional position/title

How long have your worked in your professional field?

How many hours per week do you see clients/patients?

Do you currently see couples in your practice?

If you answered Yes, what percentage of your current practice is couple work?

How long have you been consulting to / supervising therapists?You must be currently consulting for at least 1 hour per week to participate in the PPCP program.

How many hours per week do you currently provide consultation/supervision?

Describe your professional practice

Describe the patient populations you serve, therapy modalities, frequencies of seeing patients, setting: public, private, etc.

Describe your experience with evaluation, diagnosis, and treatment planning:

Describe your experience working with diverse populations:

Supervision Experience

Describe your supervision experience to date (both within IPI and other institutions)

Please provide type of supervision (dynamic,cognitive behavioral, etc.), duration and frequency

Personal Psychotherapy / Psychoanalysis

2 years of personal therapy/analysis within the last 10 years, or begun at the start of the program, are required for the Clinical Certificate.Exceptions will be considered by the PPP committee on a case-by-case basis.

Enrolling in the Combined Child Program requires twice per week psychotherapy with an analytic psychotherapist

If you chose Other above, please explain

Describe your psychotherapy experience

Please give dates, length of treatment, frequency, training level of therapist/analyst.

You may contact my therapist to confirm attendance only - list therapist name and phone number (IPI is a non-reporting institute)

Describe your psychoanalysis experience

duration of analysis, and the frequency of sessions on the couch

If your analyst is not a member of IIPT, and you would like to continue with them in analysis during your training, please provide their contact information below. A member of the IIPT supervising analyst (SA) faculty will contact your analyst to determine whether or not their training and experience is commensurate with that of IIPT’s requirements for an analyst conducting candidate analyses. The purpose of this interview is not to discuss you or your treatment. We are a non-reporting institute and respect the absolute privacy of analyses of our candidates. Rather, the purpose of this contact is to determine whether the analyst meets the requirements of our institute for providing personal analysis to a candidate in training and would be supportive of our method of training.

Child Program Prerequisite/Co-requisite

Have you completed Infant Observation?

If you answered yes to completing Infant Observation, please enter the Institute name, # of Hours and Date of completion

Professional Reference(s)

Please enter name and contact information for your professional reference who will submit a letter on your behalf *

Letters can be uploaded (put a link here), emailed to whichemail@theipi?, or mailed to 6917 Arlington Road, Suite 204, Bethesda, MD, 20814, USA

Please enter a second name and contact information for your professional reference who will submit a letter on your behalf *

Letters can be uploaded (put a link here), emailed to whichemail@theipi?, or mailed to 6917 Arlington Road, Suite 204, Bethesda, MD, 20814, USA

Please enter a third name and contact information for your professional reference who will submit a letter on your behalf *

Letters can be uploaded (put a link here), emailed to whichemail@theipi?, or mailed to 6917 Arlington Road, Suite 204, Bethesda, MD, 20814, USA

Statement of Interest

Describe your interest in this program. *

Please give your reasoning for pursuing training at the IPI through this certificate program. What are your professional goals?

Permissions and Guarantees

Upload a copy of your current License(s)

Please include an English translation if applicable

Upload a copy of your current Malpractice Insurance

Please include an English translation if applicable

Upload your Resume or CV *

Please include an English translation if applicable

International Psychotherapy Institute Program Application

Personal Information

Training

Training and experience with children

Professional Practice

Supervision Experience

Personal Psychotherapy / Psychoanalysis

Child Program Prerequisite/Co-requisite

Professional Reference(s)

Statement of Interest

Permissions and Guarantees

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