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Confederation of Independent Psychoanalytic Societies
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Home
About
Who we are
Governance
President’s Letter
Membership
Membership
Membership Renewal
Honorary Members
Directory
Members Only
Members Roster
Find an Analyst
Find a Clinic
Scholarly Life
Videoconferences
Book Series
Certification
NewsBriefs
NewsBriefs Summer 2024
NewsBriefs Fall 2023
NewsBriefs Winter 2023
NewsBriefs Spring 2022
Contact
CIPS Membership Application Form
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CIPS Membership Application Form
Membership Application 2024
Personal Information
Name
*
Name
First
First
Last
Last
Address
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email Address
*
Phone Number
*
Professional Information
Highest Degree Earned
*
Discipline
*
(e.g., psychiatry, psychology, social work, etc.)
License #
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you a graduate of a formal psychoanalytic training program?
*
Yes
No
If yes, which institution?
Graduation Date
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If no, on a separate attached sheet, please describe the background and expertise you have developed which may quality you to practice psychoanalysis.
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Maximum file size: 209.72MB
Are you an IPA member?
*
Yes
No
Have you had any licensing board or professional ethics body require you to surrender your license?
*
Yes
No
If yes, please give particulars and verification on a separate attached sheet.
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Maximum file size: 209.72MB
Are there currently, or have there ever been any complaints or charges pending or filed against you with any licensing board or professional body for violation(s) of a code of ethics, professional misconduct, unprofessional misconduct, unprofessional conduct, incompetence, or negligence in any state or county?
*
Yes
No
If yes, please give particulars and verification on a separate attached sheet.
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Maximum file size: 209.72MB
Have you ever been found guilty of a violation of a code of ethics, professional misconduct, unprofessional misconduct incompetence, or negligence I any state or country?
*
Yes
No
If yes, please give particulars and verification on a separate attached sheet.
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Maximum file size: 209.72MB
Have you ever been compelled to appear in court regarding a criminal manner?
*
Yes
No
If yes, please give particulars on a separate attached sheet.
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Maximum file size: 209.72MB
Please supply the following information concerning your malpractice coverage:
Name of Company
Coverage termination date
Policy Number
Limits of Coverage
Terms and conditions
*
I understand that this form collects my name, email, address, and phone number so I can be contacted.
I have read and agree with CIPS
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