Application for Board Certification Graduate Analyst Application Full Name Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona 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 State/Province Zip/Postal Zip/Postal Email Address Phone Number License Institute Name Date of Graduation Experience Since graduation, approximately how many total hours have you devoted to the practice of formal psychoanalysis, conducted at a minimum of 3-5 sessions per week? Total Hours Since graduation, how many patients have you treated in formal psychoanalysis, conducted at a minimum frequency of 3-5 sessions per week? Total Patients Patient Experience Experience in the conduct of psychoanalytically informed individual psychotherapy and formal psychoanalysis (at a minimum frequency of 3-5 sessions per week): Click the "Add New Patient" button below to add multiple patients. Add Patient Information PT Number Year Tx initiated Year Tx Terminated Clinical Consultants and/or Supervisors Add New Patient Remove Patient For each patient, please list the approximate start date and, if appropriate, the termination date. If the case is ongoing, write "ongoing" in the termination column. Please list all patients seen AFTER graduation, even if their treatment began before graduation. If necessary, add rows to include all patients seen in the last five years. Supervision & Consultation Since Graduation Please list all supervisors, teachers, and clinical consultants with whom you have studied or discussed your work since graduation. Last Five Years Please list all supervisors, teachers, and clinical consultants with whom you have studied or discussed your work in the last five years. Since graduation, approximately how many total hours have you devoted to the practice of psychoanalytic treatment (formal psychoanalysis and psychoanalytically informed psychotherapy)? Total Hours Seminars & Study Groups Since Graduation Please list all seminars and study groups, including dates and group leaders, in which you have participated since graduation. Last Five Years Please list all seminars and study groups, including dates and group leaders, in which you have participated during the last five years. Teaching Please describe your experience teaching psychoanalytic theory or psychoanalytic practice technique. Include courses and the year you taught them. (no more than 150 words). Professional Activities in Psychoanalysis Supervising Please describe your experience supervising candidates, students, or mental health practitioners in the practice of psychoanalysis or psychoanalytically informed psychotherapy. Please include years. (no more than 150 words). Research Please describe your experience conducting research in psychoanalytic theory or psychoanalytically informed practice. (no more than 150 words) Publications Please list your publications pertaining to psychoanalytic theory, treatment, education or research since graduation. Seminars and Study Groups Led Please list and describe any psychoanalytically oriented seminars or study groups you have led since graduation. This application requires two letters of reference from colleagues. Download the form here and send it to your references complete with the instructions for returning to CIPS. Submit Become a Member Click Here
