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      THE METROPOLITAN INSTITUTE
    FOR TRAINING IN PSYCHOANALYTIC PSYCHOTHERAPY

 
PLEASE TYPE OR PRINT CLEARLY

Date _________________


Name____________________________________ Sex M ___ F___ 

Address ________________________________________________________________


_______________________________________________________________

Home Telephone _____________ Work Telephone____________Cell _______________

Email______________________________ Fax ________________________________

Discipline (e.g. social work, psychology, 
etc.)_____________________________________

Graduate Degree____________________ Year Obtained 
_________________________

School__________________________________________________________________

Undergraduate Degree_________________ Year Obtained 
________________________

School __________________________________________________________________

N.Y. State Certification or License No. 
______________________________________

Please check one (requirements for all programs include supervision and 
personal therapy, with the exception of non-matriculated coursework):

_________ Full-time Adult Program (3 courses per semester and 8 clinical 
hours per week)
_________ Part-time Adult Program (1 or 2 courses per semester, 5 clinical 
hours per week)
_________ Full-time Adult Program: LCSW Track (3 courses and 10, 15 or 20 
clinical hours weekly)
_________ Part-time Adult Program: LCSW Track (1 or 2 courses and 10, 15 or 
20 clinical hours weekly)
_________ Full-time Adult Program: Psychoanalytic Licensure (8 clinical 
hours per week)
_________ Part-time Adult Program: Psychoanalytic Licensure (1 or 2 courses 
per semester, 5 clinical hours per week)
_________ Non-matriculated coursework: Adult Program (coursework only)
_________ Clinical Training in Child & Adolescent Psychotherapy (2 courses 
per semester, 5 clinical hours weekly)
_________ Clinical Training in Child & Adolescent Psychotherapy LCSW Track 
(2 courses per semester, 10 clinical hours weekly for 
two years followed by individual and group supervision and a 
minimum of one course per semester in the Adult Program and 10 
clinical hours weekly until the hours for the LCSW 
have been accrued.)
_________ Non-matriculated coursework: Child & Adolescent Program 
(coursework only)Please check one:

I am applying for the Fall semester ________ Year ______

Spring semester _________ Year ______

Current Employment:

Position _____________________________________________________________

Name of Employer ____________________________________________________

Address _____________________________________________________________


Personal Psychotherapy/Psychoanalysis: (List current or most recent 
therapy)

Name of Therapist/Analyst ________________________________________________

Therapist's Affiliation(s) if 
known___________________________________________ 

______________________________________________________________________

Dates of Treatment: from__________________ to______________________________

Frequency of Sessions ____________________________________________________


Please list all previous personal therapy/analysis:

Name of Therapist/Analyst ________________________________________________

Therapist's Affiliation(s) if known 
___________________________________________

______________________________________________________________________

Dates of Treatment: from __________________ to 
_____________________________

Frequency of Sessions _____________________________________________________

Name of Therapist/Analyst ________________________________________________

Therapist's Affiliation(s) if known: 
___________________________________________

______________________________________________________________________

Dates of Treatment: from_________________ to ________
_______________________

Frequency of Sessions______________________________________________________

How did you learn about MITPP? __________________________________________

_______________________________________________________________________



Please include:

o MITPP Application for Training.
o $50.00 non-refundable application fee.
o An up-to-date curriculum vita (resume).

Send to: 
Joyce A. Lerner, L.C.S.W., Director
MITPP
160 West 86th Street
New York, New York 10024


NOTE: Two letters of reference on letterhead from current or former 
supervisors, teachers, administrators or other such professionals who have overseen your 
work must be forwarded to MITPP by the writer on your behalf.

Painting-"The Law of One" by Ariyon Deborah Salt www.ariyon.com