Emory University Psychoanalytic Institute Application
For classes starting Fall 2016

For information, please see: http://psychiatry.emory.edu/education/eupi/index.html

Applications require 4 parts:
1. This completed survey. If response space is not adequate for a survey question(s), please include additional data (noting question #) in your email with CV, per #2 below.
2. Your CV - attached to an email sent to Amy: acromwe@emory.edu with SUBJECT: EUPI Application-CV (your name here). 
3. Any publications that are relevant to this application. (PDF links OK in email above, or if originals, deliver to Amy at Tufts House. All these originals will be returned.)
4. An application fee of $25, payable by check made out to "EUPI" with "2016-2017 Application Fee" on memo line.  Hand deliver or mail to EUPI, Attn: Amy Cromwell, Tufts House-Room 302, 2004 Ridgewood Dr NE, Atlanta, GA 30322. 
 
 

To which of our three programs are you applying:

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* 1. To which of our three programs are you applying:

Name and Terminal Degree if applicable (ex: MD, PhD, LCSW...)

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* 2. Name and Terminal Degree if applicable (ex: MD, PhD, LCSW...)

Preferred email address:

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* 3. Preferred email address:

Street address 1:

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* 4. Street address 1:

Street address 2:

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* 5. Street address 2:

City, State, Zip:

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* 6. City, State, Zip:

Telephone number(s):

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* 7. Telephone number(s):

Place of birth:

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* 8. Place of birth:

Citizenship:

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* 9. Citizenship:

Current position:

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* 10. Current position:

College/university attended, with start and end dates, and degree awarded if applicable:

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* 11. College/university attended, with start and end dates, and degree awarded if applicable:

Academic/Professional honors and awards:

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* 12. Academic/Professional honors and awards:

Board Certifications (if applicable), type and expiration date:

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* 13. Board Certifications (if applicable), type and expiration date:

Licensed to practice in these states (if applicable):

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* 14. Licensed to practice in these states (if applicable):

Briefly describe your major area of scholarship and/or research you have conducted.

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* 15. Briefly describe your major area of scholarship and/or research you have conducted.

Briefly describe your experience as a clinician (numbers of years, full time vs. part time, types of patients and therapies, post-training supervision) and/or professional activities (teaching, research, administrative):

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* 16. Briefly describe your experience as a clinician (numbers of years, full time vs. part time, types of patients and therapies, post-training supervision) and/or professional activities (teaching, research, administrative):

Other educational or professional activities:

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* 17. Other educational or professional activities:

Memberships in professional organizations:

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* 18. Memberships in professional organizations:

Previous applications to psychoanalytic institutes (where, when, results):

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* 19. Previous applications to psychoanalytic institutes (where, when, results):

Previous completed courses at a psychoanalytic institute:

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* 20. Previous completed courses at a psychoanalytic institute:

Any important health issues you want to consider in light of the demands of our program:

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* 21. Any important health issues you want to consider in light of the demands of our program:

Any other information that would be relevant to your interest in psychoanalysis:

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* 22. Any other information that would be relevant to your interest in psychoanalysis:

Has your license ever been revoked, suspended, or otherwise restricted? If so, please explain:

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* 23. Has your license ever been revoked, suspended, or otherwise restricted? If so, please explain:

Have there been any malpractice suits or ethical complaints brought against you? If so, please explain:

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* 24. Have there been any malpractice suits or ethical complaints brought against you? If so, please explain:

Please provide your four references below (name, title, email, phone number). The first should be the chair of the department or director of studies in which you received your relevant degree.

NOTE: You must contact these people and request that a reference be sent directly from them to EUPI, preferably as a pdf attachment to an email to Amy at acromwe@emory.edu, with "SUBJECT: EUPI Letter of Reference for (your name)". If snail mailed, send to Amy at:

EUPI-Tufts House, Room 302
Attention: Amy Cromwell
2004 Ridgewood Drive NE
Atlanta, GA 30322

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* 25. Please provide your four references below (name, title, email, phone number). The first should be the chair of the department or director of studies in which you received your relevant degree.

NOTE: You must contact these people and request that a reference be sent directly from them to EUPI, preferably as a pdf attachment to an email to Amy at acromwe@emory.edu, with "SUBJECT: EUPI Letter of Reference for (your name)". If snail mailed, send to Amy at:

EUPI-Tufts House, Room 302
Attention: Amy Cromwell
2004 Ridgewood Drive NE
Atlanta, GA 30322

We will never ask for a release of your personal psychoanalysis or psychotherapy for any reason. However, during your interviews, we routinely ask about your experience(s) in treatment.
Thank you for applying to our program! Additional comments may be entered below:

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* 26. Thank you for applying to our program! Additional comments may be entered below:

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