MICHIGAN PSYCHOANALYTIC COUNCIL

 

Suanne Zager, MSW, CSW, BCD                     Jeffrey Glindmeyer, Ed.D.

     Co-Chair, Psychoanalytic Study Program        Co-Chair, Psychoanalytic Study Program

                         518 LaSalle Blvd.                      4031 W. Main St. Ste. 300, P. O. Box 19155

                        Lansing, MI 48912-4222                            Kalamazoo, MI 49019-0155

 

 

Application for Psychoanalytic Psychotherapy Certificate Program

 

 

Instructions:

 

Applicants are requested to complete this application form.  Additional pages may be attached if more room is needed to complete responses. 

 

Application checklist:

 

_____   Include your current resume.

 

_____   Arrange for official transcripts of all graduate degrees or training to be submitted.

 

_____   Include a copy of your Professional License and a copy of a current face sheet of

your liability insurance. All applicants in the program must be licensed to practice psychotherapy in the state of Michigan and have professional liability insurance for their psychotherapy practices.

 

_____   Provide two letters of recommendation from professionals in your field who know you

and are familiar with your work.  One of these letters should be from a prior or current supervisor.

 

       _____  Send 2 copies of complete application form to either one of the co-chairs listed     

                   above. Also include a non-refundable application fee of $25.00.

 

 

Students must be members of MPC in order to take courses. You may submit the membership application and membership fee ($125.00 full/$40.00 student) with this application for training. (A copy of the application for membership may be obtained on the MPC website MPCPSA.ORG.)

 

Personal Information:

 

 

Date of Application: __________________

 

Full Name:        ______________________________________________________________________

 

Address (Residence):     _________________________________________________________

_____________________________________________________________________________

Phone: ______________________

 

Address (Professional):  _________________________________________________________

_____________________________________________________________________________

Phone: ______________________

 

            Professional License: ________License _______Certification ________Other ________

 

STATE:                                                             No.:

_______________________________                              ____________________

 

_______________________________                              ____________________

 

 

Are you in good standing with your professional body?  Yes_________   No_______

 

If no, please explain.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Professional Practice

 

Are you in professional practice now?      Yes      ______              No        ______

 

If yes, when did you begin this practice? _________________________

 

Current Work Setting___________________________________________________________

____________________________________________________________________________

 

Please describe the ordinary activities of your practice or academic work (i.e., average number of hrs/week in individual, marital, or family practice, group therapy, testing and diagnostics, teaching, and other professional work.)

 

 

 

 

 

 

 

Is your work supervised now?      Yes      _____               No        _____

If yes, list the names, addresses and telephone numbers of your current supervisor(s), and the dates between which they supervised your work.

 

 

 

 

 

Do we have permission to contact supervisors for information about your work?

Yes      ____                 No _____   Reason________________________________________

 

Other Experience

 

List professional experience in addition to those already described.  For each work setting or experience, describe the number of hours and the types of professional work.  Please provide name, address, and phone numbers of supervisors, if appropriate, and the dates between which they supervised your work.  Take as many pages as you need to respond.  If you cannot provide exact information, please give approximate information, but qualify it as "approximate."  If there were more than six work settings, please describe just the six most important.

 

 

 

 

 

 

 

 

 

Personal Therapy:

 

Are you in analysis or therapy now?                    Yes      _____               No        _____

 

Have you ever been in analysis or therapy?          Yes      _____               No        _____

 

Name and current address of current analyst (therapist) or of person seen most recently:

 

Name:   ____________________________________         Degree:    _______________________

 

Address:___________________________________________________________________________________________________________________________________________________

 

 

 

The following information is requested about your current (or most recent) experience in analysis or therapy.  (If you have never been in analysis or therapy, please skip now to the questions about previous psychoanalytic coursework).

 

Summary of analysis or therapy:

 

When did you begin (Month, Year):          _________________________

Please summarize the therapy as follows:

 

_____   weeks at frequency of 3 or more times/week

 

_____   weeks at frequency of 2 times/week

 

_____   weeks at frequency of once/week

 

_____   weeks at other time arrangement (please specify)   

 

 

If you have been in analysis or therapy with more than one individual, please summarize your previous experience below, including the amount of time and at what frequency.  List also the affiliation of your analyst or therapist, if known.

 

 

 

 

 

Please note: The information about personal psychoanalysis or therapy may be used in guiding an individual to the possible necessity of further analytic work.  However, this organization will not communicate personally with your therapist or analyst.  It will be the responsibility of the applicant to contact the analyst/therapist, if requested, to provide direct verification only of the total number of hours and frequency.

 

 

Previous Psychotherapeutic and/or Psychoanalytic Coursework or Training

 

 

1. Have you taken courses of a psychoanalytic nature through any other organization?  If yes, please specify, including name of organization sponsoring course, instructor (including professional degree), and length of time attended and frequency at which class was offered.

 

 

 

 

 

2. Do you think you have taken an equivalent of any required or elective MPC course in your earlier work?  If yes, please specify.

 

 

 

 

 

 

 

                                                                                                           

Please list any additional relevant information which you feel is important, but for which there did not seem to be a place in this application.

 

 

You may send your applications to either:

Suanne Zager, MSW, CSW, BCD                     Jeffrey Glindmeyer, Ed.D.

     Co-Chair, Psychoanalytic Study Program        Co-Chair, Psychoanalytic Study Program

                         518 LaSalle Blvd.                      4031 W. Main St. Ste. 300, P. O. Box 19155

          Lansing, MI 48912-4222                            Kalamazoo, MI 49019-0155