Telephone: (415) 563-5815

www.sf-cp.org

ELECTRONIC APPLICATION FOR ADMISSION

Psychoanalytic Psychotherapy Training Program (PPTP)Foundations of Psychoanalytic Psychotherapy Program

PPTP (Psychoanalytic Psychotherapy Training Program)

The Psychoanalytic Psychotherapy Program (“PPTP”) is a two-year training program of integrated didactic courses, case conferences, supervision, and mentorship. PPTP trainees are enrolled automatically as Community Members of SFCP. Enrollment in the PPTP program requires a two-year commitment for the academic years 2018-2019 and 2019-2020 (from September through mid-June each year). See SFCP’s website for a fuller description of the PPTP program.

Foundations of Psychoanalytic Psychotherapy

Foundations of Psychoanalytic Psychotherapy (“Foundations”) is a one-year educational program in which students join the first-year PPTP cohort for one year of coursework only, but do not participate in the supervised psychotherapy component of PPTP or in the second year of classes. Foundations students also are offered mentorship and are automatically enrolled as Community Members of SFCP. Students who enroll in Foundations may apply to transition into PPTP at a later time. Enrollment in Foundations requires a one-year commitment for the academic year September 2018 through mid-June 2019. Please note that applications to the two-year PPTP program will be prioritized over applications to Foundations in our Admissions process. See SFCP’s website for a fuller description of the Foundations program.

Submitting an application to PPTP or to Foundations

Applicants to either PPTP or Foundations must submit this electronic application as well as supplemental materials and application fee requested below. Applications will not be considered complete until all application materials and fees have been received by the SFCP Office. Applicants who submit completed applications by April 11, 2018 at 9:00 AM will be guaranteed consideration for matriculation in September 2018. Applications submitted after 9:00 AM on April 11, 2018 will be considered only if there are spots available after on-time applicants have been offered admission. In recent years, there have been more applicants than positions. Admissions decisions for PPTP and Foundations are completed by mid-June. Qualified applicants who are not offered 2018 admission may be offered a position on the 2018 waiting list.

How to apply

Please complete this entire form in Microsoft Word and email it to pptp@sf-cp.org. Answers should be typed into the grey boxes. Please note that these grey boxes will expand to accommodate answers of any length. In addition to this form, we request supporting documents which are described further below. If you have any difficulties downloading this application, please email pptp@sf-cp.org.

Your complete application, application fee, and ALL supporting documents including Letter of Reference must be received by 9:00 AM on April 11, 2018 to be considered for Fall 2018.

WE RECOMMEND SUBMITTING YOUR APPLICATION PRIOR TO THE DEADLINE so you will have flexibility in scheduling your interview and time to address any incomplete components before the deadline passes.

For questions regarding the application process, please contact Admissions Chair Genie Dvorak at drgeniedvorak@gmail.com.

PPTP AND FOUNDATIONS ATTENDANCE COMMITMENT

The Admissions Committee is working to ensure that the group of students beginning classes in Fall 2018 will be committed to participating throughout the duration of the program, without departures or extended leaves of absence. Such commitment is critical to maintaining cohesive groups which are at the core of the PPTP learning experience. Further, consistent class attendance is crucial as groups develop a coherent body of clinical and theoretical material, as well as a group identity, that they build on together throughout the program. If minimum class attendance requirements are not met, the course must be repeated the following year. [See Training Manual on our website for a full description of the Attendance Policy].

Because of the importance of group cohesion and stability to the educational experience, we would like you to consider whether — barring unforeseeable and unlikely circumstances — you can make a firm commitment to consistently attend class throughout the duration of the program to which you are accepted. Examples of circumstances which have posed a challenge in the past include: (1) professional responsibilities such as fellowships, demanding jobs, and call schedules; (2) family responsibilities such as infant/childcare or caring for an ailing family member; and (3) personal circumstances such as travel plans, planned leaves of absence, or a partner’s relocation away from the Bay Area. If you anticipate that these or similar circumstances may prevent you from beginning the program or from attending consistently throughout the program, we ask that you contact us to discuss your situation before you apply.

We realize that some of you may be uncertain of your plans at the time of the application deadline on April 11, 2018. In the section below, please provide information about your situation, describing your degree of uncertainty and when you expect to know your plans more clearly. This will help determine whether you should apply to PPTP or to Foundations. Please be aware that if you are accepted to either program, you will be asked to make a commitment regarding attendance and to submit a non-refundable deposit on July 2, 2018 to secure a spot in the Fall 2018 class (see Cost of PPTP/Foundations section for full fee schedule).

Finally, students in the PPTP program must be working in a clinical setting where they can see adult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week. If you do not have this option, please apply to Foundations.

Note: If you enroll in Foundations, you may convert to PPTP at any time if your circumstances change.

GUIDE TO DETERMINING WHETHER TO APPLY TO PPTP OR TO FOUNDATIONS

Check ONE of the grey boxes below and provide the requested information:

I am confident that I will be able to matriculate in Fall 2018 and to commit to attending class consistently throughout the 2018-2019 and 2019-2020 academic years, from September to mid-June each year. I will be working in a clinical setting where I can see adult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week.Apply to the two-year PPTP program

Please briefly describe your professional plans and the clinical setting in which you will be working:      

I am attempting to make arrangements to be able to matriculate in Fall 2018 and to attend class consistently throughout the 2018-2019 and 2019-2020 academic years from September to mid-June. I expect to be working in a clinical setting where I can see adult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week. However, my professional/personal plans are still awaiting confirmation. I will update the Admissions Committee as soon as possible as my plans become clearer.Apply to the two-year PPTP program if you expect clarification before July 2, 2018Apply to the one-year Foundations program if you expect clarification after July 2, 2018

Please briefly describe your intended professional plans and clinical setting in which you hope to work:      

Please briefly describe the factors contributing to the uncertainty in your plans (e.g. waiting to hear about a job, waiting to hear if a partner needs to relocate, etc.):      

Please let us know the date by which you expect your plans to become clear:      

I am confident that I will be able to matriculate in Fall 2018 and to commit to attend class consistently from September 2018 through mid-June 2019, but I have plans which prevent me from committing to attend in 2019-2020 (e.g. applying to Fellowships, possibly moving, possibly taking an extended leave of absence).Apply to the one-year Foundations program with the option to convert to PPTP

Please briefly describe your professional plans and the clinical setting in which you will be working:      

I am confident that I will be able to matriculate in Fall 2018 and to commit to attend class consistently from September 2018 through mid-June 2019, but I will not be working in a clinical setting where I can see adult patients in open-ended psychoanalytic psychotherapy at a frequency of one to two times per week.Apply to the one-year Foundations program with the option to convert to PPTP

Please briefly describe your professional situation:      

I am interested in applying to PPTP/Foundations; however, my plans and level of commitment are

uncertain at this time.Before applying, contact Genie Dvorak, Admissions Chair at drgeniedvorak@gmail.com to discuss

Please briefly describe your situation:      

PROGRAM APPLICATION AND DECLARATION OF AVAILABILITY

You will be notified by mid-June regarding the outcome of your application to PPTP or Foundations. If you are offered admission, a non-refundable deposit will be due by July 2, 2018 to secure your spot in the program. If you choose to accept the offer of admission, we will ask you to confirm that — barring unforeseeable, unavoidable circumstance — you will attend class regularly and participate fully throughout the duration of your program. After July 2, 2018, any unsecured spots will be offered to waitlisted applicants.

Please use the GUIDE TO DETERMINING WHETHER TO APPLY TO PPTP OR FOUNDATIONS (previous section) to make your decision. If there are any updates or changes in your anticipated availability, please contact the Admissions Committee immediately. If you have questions or would like to discuss your specific situation, you are welcome to contact Genie Dvorak (Admissions Chair) or any of us on the PPTP Committee.

I am applying to PPTP and understand that, if I am accepted and wish to secure a spot in the program, I will be asked to commit to attending class consistently throughout the 2018-2019 and 2019-2020 academic years (September through mid-June) and to provide a non-refundable deposit by July 2, 2018. In the interim, I will inform the Admissions Committee as soon as possible of any updates or changes in my availability.

I am applying to Foundations and understand that, if I am accepted and wish to secure a spot in the program, I will be asked to commit to attending class consistently for the academic year September 2018 through mid-June 2019 and to provide a non-refundable deposit by July 2, 2018. In the interim, I will inform the Admissions Committee as soon as possible of any updates or changes in my availability.

PERSONAL INFORMATION

Name:       Degree:      

Date of Application:      

Office address:      

Home Address:      

Required contact information:

Personal mobile number:      

Personal email (not work):      

Preferred Contact Information (if different):

Telephone:      

Email:      

Gender:       Date of birth:       Age:       Social Security #:      

LICENSURE

If you are licensed, please fill out this section.

Professional License Number:       State:      

Professional Liability Insurance:      

Board Certification

(if applicable):

Certifying board:     

Date of certification:      

SUPERVISOR’S LICENSE AND LIABILITY INSURANCE

If you are not licensed and insured, you may still apply to PPTP if you are working under the professional liability insurance of a supervisor or organization. If you are working under a supervisor’s license and professional liability insurance, please fill out this section.

Note: If you are unlicensed and not working under a supervisor’s license and professional liability insurance, please apply to Foundations.

Name of supervisor:      

Supervisor’s Professional License Number:       State:      

Supervisor’s Professional Liability Insurance:      

EDUCATION AND TRAINING

Please include all undergraduate and graduate experience

Institution Dates attended

Degree Year

                       

                       

                       

                       

                       

CLINICAL TRAINING PLACEMENTS

Please list all of the training placements (assistantships, internships, post-doctoral placements, medical residencies, fellowships, etc.) you have completed during the last seven years.

Institution Position Dates

                 

                 

                 

                 

                 

RELEVANT CLINICAL WORK EXPERIENCE

Briefly describe clinical work experience. Include years in practice, clinical settings (e.g.: agency, hospital, private practice, etc.), average patient hours per week, and nature of practice (e.g., modality, frequency, type of patients, etc.)

(1) Work setting:       Dates:      

Position/Description:      

(2) Work setting:       Dates:      

Position/Description:      

(3) Work setting:       Dates:      

Position/Description:      

(4) Work setting:       Dates:      

Position/Description:      

(5) Work setting:       Dates:      

Position/Description:      

TEACHING, RESEARCH, PUBLICATION, SUPERVISORY EXPERIENCE

If applicable, briefly describe.

     

OTHER RELATED PROFESSIONAL EXPERIENCES

List classes, seminars, consultation, and other educational experiences in which you have participated outside of your formal training placements. Please specify if any of these have been of a psychoanalytic nature.

     

PROFESSIONAL MEMBERSHIPS

     

PSYCHOANALYSIS OR PSYCHOTHERAPY

If you are comfortable doing so, please provide additional information about your past and current treatments below. Although we are interested in this information, be assured that personal treatment is not a prerequisite for participation in PPTP.

Have you been in psychoanalysis or psychotherapy?

Type of treatment

Note: Please do not provide names of psychotherapists or psychoanalysts you have seen.

Session frequency

Year treatment began

Year Treatment ended

(1)                        

(2)                        

(3)                        

PERSONAL STATEMENT

In the space below, please tell us about yourself in any way that you think would be helpful, including your reasons for and what you hope to achieve in undertaking a training program in psychoanalytic psychotherapy. (Please offer a substantial response so that we may get to know you, but limit length to two pages.)

     

LETTER OF REFERENCE

Someone familiar with your clinical work or training should email us a letter of reference directly. Please provide the name your reference below, including the context in which he or she knows your work and ask this individual to email the letter to pptp@sf-cp.org .

     

ADDITIONAL INFORMATION

In this optional section, please add anything else you would like the Admissions Committee to know in considering your application.

     

DECLARATION OF LEGAL AND ETHICAL STANDING

Has there ever been a complaint of ethical misconduct or unprofessional conduct brought against you that resulted in a determination of misconduct and ensuing sanction?

YES NO

Has there ever been a complaint or investigation of you concerning impairment? YES NO

Have you ever been suspended from teaching or administrative functions in relation to a professional ethics or impairment issue?

YES NO

Has your membership in a professional or educational organization ever been suspended or terminated in relation to a professional ethics or impairment issue?

YES NO

Has there ever been a finding against you by a professional licensing board? YES NO

If your answer to any of these questions is “Yes,” please explain at greater length:      

SFCP COMMUNITY MEMBERSHIP ENROLLMENT

Enrollment in PPTP or Foundations automatically includes Community Membership in SFCP and waiver of the usual fee for this membership. (See SFCP website for Community Membership benefits.) Community Members are included in the printed and on-line member roster for SFCP.

Please fill out the following information, so that this page may be forwarded directly to Community Membership enrollment:Name:       Profession/Degree:      Address:      Work Telephone:      

Fax:      Email:      

Once enrolled in PPTP or Foundations, your member information will be included in the SFCP roster and SFCP website unless you check the space below:

DO NOT include my information in the printed roster

DO NOT include my information in the on-line roster

Other comments:      

APPLICATION FEE AND CREDIT CARD INFORMATION

Please submit a credit card number (or a debit card number with credit card functionality) to which we will charge your $50 application fee at the time you apply.

If you are offered admission to PPTP or to Foundations and accept the offer, your $50 application fee will be applied toward your tuition. We will use this credit card information (or replacement information you provide in the future) as your payment method for tuition and fees. No charges will be made without your authorization, which we will request alongside your acceptance of admission.

If you do not accept our offer of admission, no further charges will be made, and we will destroy our record of your credit card number. Your $50 application fee is non-refundable if you do not accept an offer of admission.

If you are not offered admission to PPTP or Foundations, your $50 application fee will be refunded to you and your credit card information will be destroyed.

Please note: this page will be kept separately from your application and destroyed if you do not enroll in PPTP or Foundations.

Name:      Personal phone:       Personal email:      

Please use the following credit card for my $50 application fee and as my payment method should I accept admission to PPTP or Foundations (can be updated any time by contacting the SFCP Office):

Credit Card Type: Visa Mastercard

Credit Card Number:      

Expiration Date:       /       (mm/yy)

3 Digit CVV Code:      

I provided my credit card information by phone to the SFCP Office at (415) 563-5815 on the following date:      .

If you have concerns about the application fee or about provision of payment information, please contact Genie Dvorak, Psy.D. at drgeniedvorak@gmail.com.

COST OF PPTP & FOUNDATIONS

Please read the following information carefully so that you have accurate expectations regarding cost of the PPTP or Foundations programs. Costs stated below are for the 2018-2019 program year (PPTP students will also pay for 2019-2020 program year as well as supervision fees).

If you accept an offer of admission to PPTP or Foundations, you will be asked to choose between the following two scheduling options for tuition payment for the 2018-2019 program year:

1. Lump Sum Tuition Payment Schedule

Charge Date Description Fee April 11, 2018 Application fee $50

July 2, 2018 Deposit (non-refundable) $768 August 14, 2018 Full tuition payment $1532

Total for Year $2350

2. Installment Tuition Payment Schedule (requires a $50 installment fee as shown below)

Charge Date Description Fee April 11, 2018 Application fee $50

July 2, 2018 Deposit (non-refundable) $768August 14, 2018 First quarter tuition $383August 14, 2018 Installment Fee $50October 30, 2018 Second quarter tuition $383January 23, 2019 Third quarter tuition $383April 2, 2019 Fourth quarter tuition $383

Total for Year $2400

The credit card you provide in this application (or any updated credit card you may provide us in the future) will be charged according to the schedule you choose.

PPTP applicants: Please note that supervision fees are additional to tuition and are arranged individually between supervisor and supervisee. See Training Manual on our website for description of supervision fees.

If you have concerns about this tuition payment schedule or other financial aspects of the program, please contact Genie Dvorak, Psy.D. at drgeniedvorak@gmail.com.

I have read and understood this information regarding cost

APPLICATION INSTRUCTIONS AND CHECKLIST

We strongly recommend submitting your application PRIOR TO the deadline so that you will have greater flexibility in scheduling your interview and time to address any incomplete components before the deadline.

**All components must be received by 9:00AM on April 11, 2017 at the latest to be considered for Fall 2018**

Please complete this application checklist:

This Microsoft Word file, with all sections complete, sent as an email attachment to pptp@sf-cp.org

submitted

Letter of reference (must be received by application deadline) requested

A curriculum vitae submitted

A copy of your California professional license (if applicable) submitted N/A

A copy of your professional liability insurance policy (if self-insured)

(If you are insured by your organization / residency, please submit evidence of this)

submitted N/A

A copy of a supervisor’s professional liability insurance policy (if you work under a supervisor and are covered by that supervisor’s liability insurance)

submitted N/A

**Please send in the application and all of your supporting documents via email in electronic form. In some cases, this will require you to scan or photograph your document and email the files or images to pptp@sf-cp.org. If you are having difficulty converting your documents to electronic form for email, please contact the SFCP Office at (415)563-5815 for assistance.

If you do not receive acknowledgment that we have received your application within one week of submission, please contact the SFCP Office at (415) 563-5815 or at pptp@sf-cp.org.

PREPARING FOR YOUR PPTP OR FOUNDATIONS INTERVIEW

Once your complete application and letter of reference have been received, an interviewer will call you to set up a meeting. Your interview will include three parts: (1) a personal conversation between you and your interviewer including how you came to be interested in this field and how PPTP/Foundations fits in with your career plans; (2) discussion of a clinical case with your interviewer; and (3) a chance for you to ask any questions you may have.

We mean this experience to be welcoming and enjoyable. It is not an evaluation of your skill as a psychoanalytic therapist. Rather, it is designed to help us get to know you, to give you a taste of how we think about and discuss cases, and to give us a sense of how you think about clinical material and work with a psychotherapy consultant at this point in your career.

You may find it helpful to review the information about the curriculum, supervision, dates for finalizing your Admissions status, tuition and deposit due dates, and other information on our website prior to your interview so that any questions you may have can be addressed at the interview.

How to Choose a Case to Discuss:Most of our applicants already have had the opportunity to work with patients in open-ended psychoanalytic /

psychodynamic psychotherapy. If this is your situation, please come prepared to discuss a session from a psychoanalytic psychotherapy treatment that you found particularly interesting or challenging.

On occasion, applicants have not yet had the opportunity to treat patients in open-ended psychoanalytic psychotherapy. If this is your situation, come prepared to discuss your work with a patient in another form of treatment. In general, try to choose a clinical case which might lend itself to psychoanalytic discussion (see next paragraph) during your interview. In general, we would prefer to discuss outpatient work to inpatient work; psychotherapy to other forms of clinical work; and less-structured forms of psychotherapy (e.g., Interpersonal Therapy) to more structured forms of therapy (e.g., Cognitive Behavioral Therapy).

In all cases, the most important thing is to choose a clinical encounter which drew attention to at least some of the following factors: (a) the patient’s emotional life, (b) your emotional response to the patient, (c) effects of early childhood on the patient’s current struggles, and/or (d) powerful dynamics in the clinical relationship.

Format of Case Discussion:The focus of this part of the interview will be the clinical process of a session rather than details of the patient's

history and presenting problems. Be prepared to start with a very brief (i.e., 5 minute maximum) description of the way the treatment started, its duration and frequency, major highlights of the patient’s early life and life story, and notable events in the treatment leading up to the session in question.

Please bring two copies of notes (one for you and one for your interviewer) that describe the back and forth of a session in transcript format. For example:

Patient: [Looking intently at me] I don’t feel like talking today ….

Clinician: [Feeling confused.] What’s holding you back?

Whenever possible, try to include detail not only of the words spoken, but of other notable details such as the patient’s affect and body language and your emotional responses to the patient. (See the bracketed portions of the above transcript.)

If you have tape-recorded a session that you wish to transcribe, this is acceptable, but we do not require or expect a literal, word-for-word transcript. Rather, present your best attempt — from notes or memory — to convey the back and forth of a session or clinical encounter in transcript format.

If you have questions or concerns about choosing a case to discuss or about the format of the discussion, please feel free to discuss this with your interviewer over the telephone or to contact Genie Dvorak, Psy.D. at drgeniedvorak@gmail.com.

We are trying to figure out best ways to reach out to interested clinicians in our community.PLEASE CHECK ALL SOURCES THAT INFLUENCED YOUR DECISION TO APPLY TO PPTP

Recommendation from a PPTP/Foundations student

Recommendation from an instructor at your training site

Paper brochure distributed by instructor Paper brochure received by US mail Google Search

Email from SFCP Recommendation from a supervisor Outreach event at training site

Other (please feel free to type in box below)     

SIGNATUREBy entering your name and the date below, you acknowledge that all information in this application is true and accurate to the best of your knowledge. Electronic submission of this form by email is equivalent to your handwritten signature.

Signature:       Date:      

For questions regarding the application process, please contact Admissions Chair Genie Dvorak at drgeniedvorak@gmail.com. For other program questions, you may contact Curriculum Chair Beth Steinberg, at besteinberg@comcast.net, Program Chair Maria Longuemare at marialonguemare@comcast.net, or Associate Program Chair Adam Goldyne at agoldynemd@mac.com.