2016 Psychoanalytic Psychotherapy Training Program Application Form
ELECTRONIC APPLICATION FOR ADMISSION
Psychoanalytic Psychotherapy Training Program (PPTP)
Foundations of Psychoanalytic Psychotherapy Program
PPTP (Psychoanalytic Psychotherapy Training Program)
The Psychoanalytic Psychotherapy Program (“PPTP”) is atwo-year training programof integrated didactic courses, case conferences, supervision, and mentorship.PPTP trainees are enrolled automatically as Community Members of SFCP. Enrollment in the PPTP program requires a two-year commitment for the academic years 2018-2019 and 2019-2020 (from September through mid-June each year).See SFCP’swebsite for a fuller description of the PPTP program.
Foundations of Psychoanalytic Psychotherapy
Foundations of Psychoanalytic Psychotherapy (“Foundations”) is a one-year educational program in which students join the first-year PPTP cohort for one year of coursework only, but do not participate in the supervised psychotherapy component of PPTP or in the second year of classes.Foundations students also are offered mentorship and are automatically enrolled as Community Members of SFCP. Students who enroll in Foundations may apply to transition into PPTP at a later time. Enrollment in Foundations requires a one-year commitment for the academic year September 2018 through mid-June 2019. Please note that applications to the two-year PPTP program will be prioritized over applications to Foundations in our Admissions process. See SFCP’swebsite for afuller description of the Foundations program.
Submitting an application to PPTP or to Foundations
Applicants to either PPTP or Foundations must submit this electronic application as well as supplemental materials and application fee requested below. Applications will not be considered complete until all application materials and fees have been received by the SFCP Office. Applicants who submit completed applications by April 11, 2018at 9:00 AMwill be guaranteed consideration for matriculation in September 2018.Applications submitted after 9:00 AM on April 11, 2018 will be considered only if there are spots availableafteron-time applicants have been offered admission. In recent years, there have been more applicants than positions. Admissions decisions for PPTP and Foundations are completed by mid-June. Qualified applicants who are not offered 2018 admission may be offered a position on the 2018 waiting list.
How to apply
Please complete this entire form in Microsoft Word and email it to . Answers should be typed into the grey boxes. Please note that these grey boxes will expand to accommodate answers of any length. In addition to this form, we request supporting documents which are described further below. If you have any difficulties downloading this application, please .
Your complete application, application fee, and ALL supporting documents including Letter of Reference must be received by 9:00 AM on April 11, 2018 to be considered for Fall 2018.
WE RECOMMEND SUBMITTING YOUR APPLICATION PRIOR TO THE DEADLINE so you will have flexibility in scheduling your interview and time to address any incomplete components before the deadline passes.
For questions regarding the application process, please contact Admissions Chair Genie Dvorakat .
PPTP AND FOUNDATIONS ATTENDANCE COMMITMENTThe Admissions Committee is workingto ensure that the group of students beginning classes in Fall 2018 will be committed to participating throughout the duration of the program, without departures or extended leaves of absence. Such commitment is critical to maintaining cohesive groups which are at the core of the PPTP learning experience. Further, consistent class attendance is crucial as groups develop a coherent body of clinical and theoretical material, as well as a group identity, that they build on together throughout the program. If minimum class attendance requirements are not met, the course must be repeated the following year. [See Training Manual on our website for a full description of the Attendance Policy].
Because of the importance of group cohesion and stability to the educational experience, we would like you to consider whether— barring unforeseeableand unlikely circumstances—you can make a firm commitment to consistently attend class throughout the duration of the program to which you are accepted. Examples of circumstances which have posed a challenge in the past include: (1) professional responsibilities such as fellowships, demanding jobs, and call schedules; (2) family responsibilities such as infant/childcare or caring for an ailing family member; and (3) personal circumstances such as travel plans, planned leaves of absence, or a partner’s relocation away from the Bay Area. If you anticipate that these or similar circumstances may prevent you from beginning the program or from attending consistently throughout the program, we ask that you contact us to discuss your situation before you apply.
We realize that some of you may be uncertain of your plans at the time of the application deadline on April 11, 2018. In the section below, please provide information about your situation, describing your degree of uncertainty and when you expect to know your plans more clearly. This will help determine whether you should apply to PPTP or to Foundations. Please be aware that if you are accepted to either program, you will be asked to make a commitment regarding attendance and to submit a non-refundable deposit on July 2, 2018 to secure a spot in the Fall 2018 class (see Cost of PPTP/Foundations section for full fee schedule).
Finally, students in the PPTP program must be working in a clinical setting where they can see adult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week. If you do not have this option, please apply to Foundations.
Note: Ifyou enroll in Foundations, youmay convert to PPTP at any time if your circumstances change.
GUIDE TO DETERMINING WHETHER TO APPLY TO PPTP OR TO FOUNDATIONS
CheckONE of the grey boxes below and provide the requested information:
I am confident that I willbe able to matriculate in Fall 2018 and to commit to attending class consistently throughout the 2018-2019 and2019-2020 academic years, from September to mid-June each year. I will be working in a clinical setting where I can seeadult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week.
Apply to the two-year PPTP program
Please briefly describe your professional plans and the clinical setting in which you will be working:
I am attempting to makearrangements to be able to matriculate in Fall 2018 and to attend class consistently throughout the 2018-2019 and 2019-2020 academic years from September to mid-June. Iexpect to be working in a clinical setting where I can seeadult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week. However, my professional/personal plans are still awaiting confirmation. I will update the Admissions Committee as soon as possible as my plans become clearer.
Apply to the two-year PPTP program if you expect clarification beforeJuly 2, 2018
Apply to the one-year Foundations program if you expect clarificationafterJuly 2, 2018
Please briefly describe your intended professional plans and clinical setting in which you hope to work:
Please briefly describe the factors contributing to the uncertainty in your plans (e.g. waiting to hear about a job, waiting to hear if a partner needs to relocate, etc.):
Please let us know the date by which you expect your plans to become clear:
I am confident that I willbe able to matriculate in Fall 2018 and to commit to attend class consistently from September 2018 through mid-June 2019, but I have plans which prevent me from committing to attend in 2019-2020 (e.g. applying to Fellowships, possibly moving, possiblytaking an extended leave of absence).
Apply to the one-year Foundations program with the option to convert to PPTP
Please briefly describe your professional plans and the clinical setting in which you will be working:
I am confident that I will be able to matriculate in Fall 2018 and to commit to attend class consistently from September 2018 through mid-June 2019, but I will not be working in a clinical setting where I can seeadult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week.
Apply to the one-year Foundations program with the option to convert to PPTP
Please briefly describe your professional situation:
I am interested in applying to PPTP/Foundations; however, my plans and level of commitment are uncertain at this time.
Before applying, contact Genie Dvorak, Admissions Chair atto discuss
Please briefly describe your situation:
PROGRAM APPLICATION AND DECLARATION OF AVAILABILITY
You will be notified bymid-June regarding the outcome of your application to PPTP or Foundations.If you are offered admission, a non-refundable deposit will be due by July 2, 2018 to secure your spot in the program. If you choose to accept the offer of admission, we will ask you to confirm that — barring unforeseeable, unavoidable circumstance —you will attend class regularly and participate fully throughout the duration of your program. After July 2, 2018, any unsecured spots will be offered to waitlisted applicants.
Please use the GUIDE TO DETERMINING WHETHER TO APPLY TO PPTP OR FOUNDATIONS (previous section) to make your decision. If there are any updates or changes in your anticipated availability, please contact the Admissions Committee immediately. If you have questions or would like to discuss your specific situation, you are welcome to contact Genie Dvorak(Admissions Chair) or any of us on the PPTP Committee.
I am applying to PPTP and understand that, if I am accepted and wish to secure a spot in the program, I will be asked to commit to attending class consistently throughout the 2018-2019 and 2019-2020 academic years (September through mid-June) and to provide a non-refundable deposit by July 2, 2018. In the interim, I will inform the Admissions Committee as soon as possible of any updates or changes in my availability.
I am applying to Foundations and understand that, if I am accepted and wish to secure a spot in the program, I will be asked to commit to attending class consistently for the academic year September 2018 through mid-June 2019 and to provide a non-refundable deposit by July 2, 2018. In the interim, I will inform the Admissions Committee as soon as possible of any updates or changes in my availability.
PERSONAL INFORMATION
Name: / Degree:
Date of Application:
Office address:
Home Address:
Requiredcontactinformation:
Personal mobile number:
Personal email (not work): / Preferred Contact Information (if different):
Telephone:
Email:
Gender: / Date of birth: / Age: / Social Security #:
LICENSURE
If you are licensed, please fill out this section.
Professional License Number: / State:
Professional Liability Insurance:
Board Certification
(if applicable): / Certifying board:
Date of certification:
SUPERVISOR’S LICENSE AND LIABILITY INSURANCE
If you are not licensed and insured, you may still apply to PPTP if you are working under the professional liability insurance of a supervisor or organization. If you are working under a supervisor’s license and professional liability insurance, please fill out this section.
Note: If you are unlicensed and not working under a supervisor’s license and professional liability insurance, please apply to Foundations.
Name of supervisor:
Supervisor’s Professional License Number: / State:
Supervisor’s Professional Liability Insurance:
EDUCATION AND TRAINING
Please include all undergraduate and graduate experience
Institution / Dates attended / Degree / Year
CLINICAL TRAINING PLACEMENTS
Please list all of the training placements (assistantships, internships, post-doctoral placements, medical residencies, fellowships, etc.) you have completed during the last seven years.
Institution / Position / Dates
RELEVANTCLINICAL WORK EXPERIENCE
Briefly describe clinical work experience. Include years in practice, clinical settings (e.g.: agency, hospital, private practice, etc.), average patient hours per week, and nature of practice (e.g., modality, frequency, type of patients, etc.)
(1) Work setting: / Dates:
Position/Description:
(2) Work setting: / Dates:
Position/Description:
(3) Work setting: / Dates:
Position/Description:
(4) Work setting: / Dates:
Position/Description:
(5) Work setting: / Dates:
Position/Description:
TEACHING, RESEARCH, PUBLICATION, SUPERVISORY EXPERIENCE
If applicable, briefly describe.
OTHER RELATED PROFESSIONAL EXPERIENCES
List classes, seminars, consultation, and other educational experiences in which you have participated outside of your formal training placements. Please specify if any of these have been of a psychoanalytic nature.
PROFESSIONAL MEMBERSHIPS
PSYCHOANALYSIS OR PSYCHOTHERAPY
If you are comfortable doing so, please provide additional information about your past and current treatments below. Although we are interested in this information, be assured that personal treatment is not a prerequisite for participation in PPTP.
Have you been inpsychoanalysis or psychotherapy?
Type of treatment
Note: Please do not provide names of psychotherapists or psychoanalysts you have seen. / Session frequency / Year treatment began / Year Treatment ended
(1)
(2)
(3)
PERSONAL STATEMENT
In the space below,please tell us about yourself in any way that you think would be helpful, including your reasons for and what you hope to achieve in undertaking a training program in psychoanalytic psychotherapy. (Please offer a substantial response so that we may get to know you, but limit length to two pages.)
LETTER OF REFERENCE
Someone familiar with your clinical work or training should email us a letter of reference directly. Please providethe name your reference below, including the context in which he or she knows your workand ask this individual to email the letter to .
ADDITIONAL INFORMATION
In this optional section, please add anything else you would like the Admissions Committee to know in considering your application.
DECLARATION OF LEGAL AND ETHICAL STANDING
Has there ever been a complaint of ethical misconduct or unprofessional conduct brought against you that resulted in a determination of misconduct and ensuing sanction? / YES NO
Has there ever been a complaint or investigation of you concerning impairment? / YES NO
Have you ever been suspended from teaching or administrative functions in relation to a professional ethics or impairment issue? / YES NO
Has your membership in a professional or educational organization ever been suspended or terminated in relation to a professional ethics or impairment issue? / YES NO
Has there ever been a finding against you by a professional licensing board? / YES NO
If your answer to any of these questions is “Yes,” please explain at greater length:
SFCP COMMUNITY MEMBERSHIP ENROLLMENT
Enrollment in PPTP or Foundationsautomatically includes Community Membership in SFCP and waiver of the usual fee for this membership. (See SFCP website for Community Membership benefits.) Community Members are included in the printed and on-line member roster for SFCP.
Please fill out the following information, so that this page may be forwarded directly to Community Membership enrollment:
Name: / Profession/Degree:
Address:
Work / Telephone:
Fax:
Email:
Once enrolled in PPTP or Foundations, your member information will be included in the SFCP roster and SFCP website unless you check the space below:
DO NOT include my information in the printed roster
DO NOT include my information in the on-line roster
Other comments:
APPLICATION FEE AND CREDIT CARD INFORMATION
Please submit a credit card number(or a debit card number with credit card functionality) to which we will charge your $50 application fee at the time you apply.
If you are offered admissionto PPTP or to Foundations and accept the offer, your $50 application fee will be applied toward your tuition. We will use this credit card information (or replacement information you provide in the future) as your payment method for tuition and fees. No charges will be made without your authorization, which we will request alongside your acceptance of admission.
If you do not accept our offer of admission, no further charges will be made, and we will destroy our record of your credit card number. Your $50 application fee is non-refundable if you do not accept an offer of admission.
If you are not offered admission to PPTP or Foundations, your $50 application fee will be refunded to you and your credit card information will be destroyed.
Please note: this page will be kept separately from your application and destroyed if you do not enroll in PPTP or Foundations.
Name:
Personal phone: / Personal email:
Please use the following credit card for my $50 application fee and as my payment method should I accept admission to PPTP or Foundations (canbe updated any time by contacting the SFCP Office):
Credit Card Type: / Visa Mastercard
Credit Card Number:
Expiration Date: / (mm/yy)
3 Digit CVV Code:
I provided my credit card information by phone to the SFCP Office at (415) 563-5815 on the following date:.
If you have concerns about the application fee or about provision of payment information, please contact Genie Dvorak, Psy.D. at .
COST OF PPTP & FOUNDATIONS
Please read the following information carefully so that you have accurate expectations regardingcost of the PPTP or Foundations programs. Costs stated below are for the 2018-2019 program year (PPTP students will also pay for 2019-2020 program year as well as supervision fees).
If youaccept an offer of admission to PPTP or Foundations, you will be asked to choose between the following two scheduling options for tuition payment for the 2018-2019 program year:
- Lump Sum Tuition Payment Schedule
April 11, 2018Application fee$50
July 2, 2018 Deposit (non-refundable)$768
August 14, 2018 Full tuition payment$1532
Total for Year$2350
- Installment Tuition Payment Schedule (requires a $50 installment fee as shown below)
April 11, 2018Application fee$50
July 2, 2018Deposit (non-refundable)$768
August 14, 2018First quarter tuition$383
August 14, 2018Installment Fee$50
October 30, 2018Second quarter tuition $383
January 23, 2019Third quarter tuition $383
April 2, 2019Fourth quarter tuition$383
Total for Year$2400
The credit card you provide in this application (or any updated credit card you may provide us in the future) will be charged according to the schedule you choose.
PPTP applicants: Please note that supervision fees are additional to tuition and are arranged individually between supervisor and supervisee. See Training Manual on our website for description of supervision fees.
If you have concerns about this tuition payment schedule or other financial aspects of the program, please contact Genie Dvorak, Psy.D. at .
I have read and understood thisinformationregarding cost
APPLICATION INSTRUCTIONS AND CHECKLIST
We strongly recommend submitting your application PRIOR TO the deadline so that you will have greater flexibility in scheduling your interview and time to address any incomplete components before the deadline.