Membership Application 2024

Personal Information

Name
Name
First
Last
Address
City
State/Province
Zip/Postal
Country

Professional Information

(e.g., psychiatry, psychology, social work, etc.)
Are you a graduate of a formal psychoanalytic training program?

Maximum file size: 516MB

Maximum file size: 516MB

Are you an IPA member?
Have you had any licensing board or professional ethics body require you to surrender your license?

Maximum file size: 516MB

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?

Maximum file size: 516MB

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?

Maximum file size: 516MB

Have you ever been compelled to appear in court regarding a criminal manner?

Maximum file size: 516MB

Please supply the following information concerning your malpractice coverage:

Terms and conditions