WESTCHESTER INSTITUTE FOR TRAINING IN PSYCHOANALYSIS AND PSYCHOTHERAPY
66 Main Street
Bedford Hills, N.Y. 10507
(914) 666-0163
CHARTERED BY THE REGENTS OF THE UNIVERSITY OF THE STATE OF NEW YORK
APPLICATION FOR TRAINING
Name and Credentials: __________________________________________________________________________ Field(s) in
which advanced degree(s) were received Home Address: __________________________________________________________________________ Home
Phone: ______________________ Office Phone: __________________ Cell phone:_________________________ Email
Address: ____________________________________________________________________ Office Address: _____________________________________________________________________ Present
Occupation: _________________________________________________________________ How long have you been employed in this
position? _________________________________________ Place of Birth: __________________________ Names of Institutions
of higher education attended with degrees granted and dates of attendance. Please have transcripts from college and graduate
schools sent to the Institute:
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ List
all licenses, certifications, or Board accreditations:
___________________________________________________ ___________________________________________________ Professional
Affiliations and Memberships:
___________________________________________________ ___________________________________________________ ___________________________________________________
Publications: _______________________________________________________________________
__________________________________________________________________________________ Director(s)
of Field Work in Graduate School: _____________________________________________ __________________________________________________________________________________ Supervisor
at Field Work Placement: ____________________________________________________ Other Clinical Experience (individual,
group, marital therapy, number of years): __________________________________________________________________________________ __________________________________________________________________________________ If
this work was supervised, please list the name(s) and address(es) of your supervisor(s): __________________________________________________________________________________ Personal
Analysis or Therapy experience (include name and address of analyst, dates started/ended): __________________________________________________________________________________ __________________________________________________________________________________ List
the names and addresses of three professional references: Please contact them and ask them to write to us on your behalf:
_________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
How did you hear of the Westchester Institute? ____________________________________________
Please attach
an application fee of $85.00 (check or money order) payable to The Westchester Institute. This fee is non-refundable. Please
attach a brief autobiographical essay. Include a statement of why you wish to attend the Westchester Institute and how you
intend to use the training, if completed.
Signature ___________________________________________Date:______________ | 
