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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:______________ | 
