The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
Psychoanalyst Form 5
Application for Limited Permit
Applicant Instructions
1. A limited permit authorizes practice as a Psychoanalyst under the general supervision of an appropriately
licensed professional, as determined by the Department. Complete Section I. You must answer all
questions in ink (pen or printer) and provide all information requested unless otherwise indicated. Failure
to complete all required parts of the application will delay its review. Be sure to sign and date item 9.
Give your prospective supervisor a copy of Appendix A along with both pages of this application. It is your
responsibility to ensure your supervisor fully completes Section II.
2. You may apply for a limited permit either at the same time as or after submitting an application for a license as a Psychoanalyst in New York State. If you
have not yet filed an Application for Licensure (Form 1) and the licensure fee ($371), you must submit them with this form and the limited permit fee.
3. Submit this application and the limited permit fee ($70) to the Office of the Professions at the address at the end of this form. The limited permit fee is not
refundable. Permits cannot be issued until all required documentation has been received and approved. The provisional permit is valid for a period
of two years. The permit may be extended for up to two additional one-year periods at the discretion of the Department. To apply for an extension, you must
submit a new Form 5 and limited permit fee ($70) along with a justification for the extension.
4. If you change supervisors or have additional settings or supervisors after a permit is issued, you must obtain an amended permit. Complete a new Form 5
with each prospective supervisor, and return it to the Office of the Professions. A new fee is not required for a permit issued as a result of a change in
supervisor or setting.
Application for Psychoanalyst
19 $70 PR
Section I: Applicant Information
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date
Month Day Year
3. Print Name
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
4. Mailing Address Home or Business
(You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
State ZIP Code
5. Telephone/Email Address
Daytime Phone
Home or Business
Area Code Phone
Email Address (please print clearly)
Home or Business
6. New York State DMV ID Number
(Driver or Non-Driver ID)
(Leave this blank if you do not have a
New York State DMV ID Number)
7. I am applying for
Original Permit (Include $70 fee)
Extension (Attach justification and include $70 fee)
Additional Setting Additional Supervisor
Change of Setting* Change of Supervisor*
*If you are applying for a change of setting or supervisor, please indicate the setting and/or supervisor being cancelled.
8. Name of prospective supervisor
9. I declare and affirm that the statements made in the foregoing application are true, complete and correct. Any false or misleading
information in, or in connection with, my application may be cause for denial of permit and certification/licensure and may result in criminal
Applicant's Signature Date
Psychoanalyst Form 5, Page 1 of 2, Rev. 3/19
Section II: Supervisor's Certification
A limited permit may be issued to an applicant who has met all requirements for licensure except the licensing examination and/or experience
requirements. The permit is valid for two years, and may be extended, at the discretion of the Department, for up to two additional one-year
Supervisor Instructions: Complete Section II to certify that the applicant will be supervised at the setting named below. You must also
attach a copy of the operating certificate or certificate of incorporation authorizing the proposed setting to employ licensed
professionals and provide services that are restricted under Title VIII of the Education Law.
Applicant's Name
(Section I, item 3)
I am licensed and currently registered to practice in New York State as a:
Physician Registered Professional Nurse Licensed Clinical Social Worker Psychologist
Nurse Practitioner in (specialty)
New York State License number Date licensed
mo. day yr.
Setting in New York State where experience will take place:
(Spell out/No abbreviation)
Zip Code
The above facility is a (check one, attach a copy of operating certificate or certificate of incorporation)
Office of Mental Health (OMH) approved setting
Office for People with Developmental Disabilities (OPWDD) approved setting
Office of Alcoholism and Substance Abuse Services (OASAS) approved setting
Department of Health (DOH) approved setting
Office of Children & Family Services (OCFS) approved setting
Department of Corrections and Community Supervision (DOCCS) approved setting
State Office for the Aging approved setting
Not-for-profit or educational corporation issued a waiver by the State Education Department
Public health agency or setting approved by the social services district
Office of a licensed Psychoanalyst (not owned by the applicant)
Office of a licensed physician, clinical social worker, or psychologist (PLLP, PLLC)
Other setting (describe)
I will supervise the permit holder in accordance with the requirements in Appendix A. I declare that the statements made in the foregoing
certification are true, complete and correct. Any false or misleading information in or in connection with this certification may be the cause for
denial of permit and licensure.
Supervisor Signature Date
Print Name
If you are applying for an original permit or renewal, mail this form and appropriate fee to: New York State Education Department, Office
of the Professions, PO Box 22063, Albany, NY 12201 U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York
State Education Department.
If you are ONLY applying for a change of, or additional supervisor/setting, mail this form to: New York State Education Department,
Office of the Professions, Psychoanalysis Unit, 89 Washington Avenue, Albany, NY 12234-1000. No fee is needed for this option.
Psychoanalyst Form 5, Page 2 of 2, Rev. 3/19