Rev: May16 Page 1 of 6 File: FPC Application
Florida Psychoanalytic Center
4649 Ponce de Leon Blvd, Suite 303
Coral Gables FL 33146
305.669.4353 v 305.740.4449 f
Instructions for Applicants for Psychoanalytic Training
1. Applications may be submitted at any time. Five (5) copies of the completed form should be
sent to Dr. Julio Calderon, Chair, Admissions Subcommittee, PO Box 940250, Miami, FL
33194. A non-refundable application fee of $350 must be included, payable to the Florida
Psychoanalytic Center. The formal application process will not begin until your application
file is complete.
2. Should your application be advanced, you will be scheduled for individual interviews with
members of the Admissions Subcommittee. The purpose of these interviews is to evaluate
your personal and professional capacities to learn about and to practice psychoanalytic
work, and will include exploring the usefulness of analysis for you personally. You should be
prepared to discuss clinical cases in detail in one or more of the interviews. Each interviewer
makes an independent recommendation to the Subcommittee, which will, in turn, review all
the data and make a recommendation for an admissions decision by the Education
Committee of the Center.
Please direct any questions you may have regarding the status of your application to the
Center’s Administrator at 305.669.4353 or by email at
Other questions should be directed to Dr. Julio Calderon, Chair, Admissions Subcommittee, at
305.275.5515 or by email at
Rev: May16 Page 2 of 6 File: FPC Application
Florida Psychoanalytic Center
4649 Ponce de Leon Blvd, Suite 303
Coral Gables FL 33146
305.669.4353 v 305.740.4449 f
Application for Psychoanalytic Training
Date _______________________
Name ________________________________________ Degree__________________________
Mailing Address ________________________________________________________________
Telephone (day) _________________________ Telephone (evening) _____________________
Email ___________________________________________ Fax __________________________
Place and Date of Birth ___________________________________________________________
Citizenship _________________________________________ Age _______________________
Current Position ________________________________________________________________
In chronological order, list your (1) colleges; (2) graduate professional schools; (3) social work
placements; (4) clinical internships; (5) residency/fellowship/post-doctoral training programs.
Name of Institution Attended Degree Year
_________________________________________ ___________ _________ _______
_________________________________________ ___________ _________ _______
_________________________________________ ___________ _________ _______
_________________________________________ ___________ _________ _______
_________________________________________ ___________ _________ _______
Academic Appointments _________________________________________________________
Professional honors and awards ___________________________________________________
Licensed to practice in following states ______________________________________________
Board Certification (specify) _______________________________________________________
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Briefly describe teaching experience, research and publications
Briefly describe your experience as a psychotherapist. Include number of years, full time/part
time, types of patients and therapies post-training supervision
Other educational or professional activities
Membership in professional organizations
Previous applications to Psychoanalytic Institutes or Centers
Present state of health ___________________________________________________________
List all past and present major illnesses
Have you had psychoanalytic _____ or psychotherapeutic _____ treatment?
List dates, frequency of sessions, duration and (optional) names of analysts or therapists
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Describe any additional information that would be relevant to your interest in psychoanalysis
Has your license to practice ever been revoked, suspended or otherwise restricted?
Yes _____ No _____
Have there been malpractice suits or ethical complaints brought against you?
Yes _____ No _____
Have you ever been denied or suspended from an appointment at an academic or clinical
institution? Yes _____ No _____
Have you ever been convicted of a felony?
Yes _____ No _____
If the answer to any of the above questions is ‘yes’, please explain in detail, using another
sheet if necessary.
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Please list 3 references of persons in positions to evaluate your work. These references may be
from the Chairman of the Department, Director of Graduate Studies or Residency Training, current
or past supervisors.
1. Name, Title and Address
2. Name, Title and Address
3. Name, Title and Address
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In addition to the above material, please submit:
1) A typed autobiography (approximately 1,000 words). The purpose of the autobiography
is to allow the Admission Subcommittee to assess your ways of understanding your own
development as a person, the important relationships and events which have
contributed to your live and the origins of your interest in psychoanalysis.
2) A typed narrative (approximately 1,000 words) of your career development, current
focus, objectives, etc.
3) A copy of your curriculum vitae.
4) Copies of your two most recent publications, if applicable.
5) Documentation of current clinical licensure and of professional liability insurance.
During your evaluation interviews you will be asked to discuss your clinical work with patients.
You may supplement this, if you wish, by also submitting along with this application, a brief
clinical report on a patient whom you have treated in psychotherapy.
I hereby authorize the Florida Psychoanalytic Center to write to the above-named references
and institutions and authorize the above-named references and institutions to release
information relevant to my application to the Florida Psychoanalytic Center. I understand that
this release does not include, nor will the Subcommittee contact, those whom I have listed as
personal analysts or therapists. I also understand that during the evaluation interviews, I may
be asked about my treatment experiences.
I attest that, to the best of my knowledge, all of the above information is true, correct and not
Signature _____________________________________________________
Date of Application _______________________________
Application Fee: A check for $350, made payable to Florida Psychoanalytic Center, should
accompany this application.