INTERNATIONAL SCHOOL FOR MENTAL HEALTH PRACTITIONERS
2295 Victory Boulevard, Staten Island, New York 10314, (718) 698-0700
(This same application may be used for Psychotherapy; Addiction Psychotherapy; Pastoral Counseling; Mediation Programs. Be sure to insert the proper program title for which you are applying.)
APPLICATION FOR ADMISSION TO PROGRAM IN PSYCHOANALYSIS
Social Security #_______________________________(you may leave blank)
Home Telephone_____________Cell Phone______________Work Phone____________
Date of Birth___________Marital Status: Single________;Married_________:Other___
If married, spouse’s full name________________________________________________
Citizen USA: Yes__No___Religion(optional)___________Ethnic Origin(optional)_____
Please attach firmly a passport photo to the reverse page)
Information Systems & Computer Applications. If you have taken this course or the equivalent, please provide documentation.
Graduate transcript(s) must be sent directly from Registrar to the Admissions Officer of ISMHP.
List all employment of the last ten years: name,location; dates; duties; reason for leaving:
Three letters of recommendation are required. These should only be from graduate professors (at least one) and supervisors (at least one) of your recent work place(s). The letter should include an assessment of your work, ethics and that you are recommended (to the best knowledge of the one writing) for psychoanalytic training and the treatment of patients. These letters are to be sent directly to the Admissions Officer of ISMHP.
Have you ever been found guilty, or pleaded guilty, no content, or nolo contendere to a crime (felony or misdemeanor) in any court? Yes _____ No ____.
Are criminal charges pending against you in any court? Yes ____ No ____.
Has any licensing or disciplinary authority refused to issue or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? Yes ____No_____
Are charges pending against you in any jurisdiction for any sort of professional misconduct? Yes ____No ____.
Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever voluntarily resigned or withdrawn from such
association to avoid imposition of such measures? Yes ___No ___.
Note: If you answer “Yes” to any of the above questions , submit a letter giving a complete detailed explanation.
It is understood that if you are accepted into the ISMHP Psychoanalytic Program, you are required, at your own expense, to carry maximum malpractice insurance which covers specifically ISMHP and any ISMHP related agencies in which your work is carried out.
I hereby certify that the information given in this application is accurate and complete to the best of my knowledge. If, I am accepted as a student, I agree to abide by the policies, philosophy of conduct, and expectations of International School for Mental Health Practitioners. I have read in its entirety the information on ISMHP including the material on history, mission, requirements, grades and fees.
State of __________________________County of ___________________________
On the ____day of _________ in the year ______, before me, the undersigned, personally appeared __________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that he / she executed the application and swore that the statements made by him / her in the application and all supporting materials are true, complete and correct.
Notary Public’s Signature________________________________________________
Notary ID number __________________
Month Day Year Notary Stamp