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Application for Associate Membership

We are pleased that you are considering applying for membership. The Membership Committee may, at its discretion, direct inquiries to supervisors and institutes noted in the application. If you have graduated from an organized training program which does not fully meet the recommended guidelines, the Membership Committee will consider any post-graduation training experiences such as seminars and private supervision. These should be documented in the application. For those not trained in organized training programs, all psychoanalytic training experiences should be documented.

IMPORTANT:

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Personal Information

Name:

Title/Degree:

Mailing Address:

Office Phone:

Fax Number:

Home Phone:

Cell Number:

Email Address:

Graduate Education

Type "N/A" if not applicable

Graduate School / Medical School:

Name of Graduate School / Medical School

Degree

Graduation Year

Psychiatric Residency / Clinical Internships:

Name of Psychiatric Residency / Clinical Internships

Graduation Year

Other Graduate Training:

Name of other Graduate Training Institutions

Graduation Year

Other Professional License:

Number

Field

State

Date

Post-Graduation Training Experiences

Please attach a page listing any Post-graduation training experiences such as private supervision, seminars, etc. Associate membership requires at a minimum completion of two years psychoanalytic study plus completion of two years of psychoanalytic case consultation in a study group or with an analyst, PPTP graduate or equivalent. Examples: Completion of PPTP or PAPPTP, a yearlong psychotherapy program plus a year of the SFCP CCSW program and two years of clinical case consultation.

Psychoanalytic Activity

Type "N/A" if not applicable

Clinical Practice:

Teaching Assignments:

Committees and Offices:

Publications / Presentations / Research / Scholarly Activities:

Memberships in Scientific Societies:

Please attach curriculum vitae if needed:

Ethical Disclaimer

The San Francisco Center for Psychoanalysis (SFCP) adheres to the Principles and Standards of Ethics for Psychoanalysts of the American Psychoanalytic Association (“APsaA”) and the Guidelines of the Ethics & Impairment Committee of SFCP.

I confirm that I have been provided access to these documents (hard copies are available upon request), have been advised to read them, and agree to abide by them.
As part of the application process, I give permission to SFCP to make inquiry for purposes of verification to the various professional organizations and licensing boards holding information pertinent to my professional qualifications, competence, or history of conduct as a professional. I understand that this inquiry will be performed in good faith by the SFCP committee responsible for the consideration of this application in consultation with the co-chairs of the SFCP Ethics and Impairment Committee. (For example, inquiry about status of your license, information from that licensing agency that is part of the public record, or inquiry to verify your faculty status at another professional organization).

I hereby certify that to my knowledge:

	Yes	No
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?
Has there ever been a complaint or investigation of you concerning impairment resulted in a determination of misconduct and ensuing sanction?
Have you ever been suspended from teaching or administrative functions in relation to a professional ethics or impairment issue?
Has your membership in a professional or educational organization ever been suspended or terminated in relation to a professional ethics or impairment issue?
Has there ever been a finding against you by a professional licensing board?

If you answered Yes to any question, please explain:

Electronic Signature

By entering your name below, you acknowledge that all of the above information is true and accurate to the best of our knowledge. Electronic submission of this form is equivalent to your handwritten signature

Your Name

Today's Date

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