SOCIETY OF MODERN PSYCHOANALYSTS

NEW Application / renewal / update / correction FORM

Note: Please circle one or more of the above. When filling out form, use other side if necessary.

PART I (PLEASE PRINT)

Name____________________________________________________________

Professional/Academic title__________________________________________

Professional Listing Address_________________________________________

________________________________________________________________

Office phone ____________________Office Fax________________________

E-mail address____________________________________________________

Second office address_______________________________________________

________________________________________________________________

Second office phone___________________Second Fax___________________

Home address_____________________________________________________

Home phone________________________Home Fax______________________

Choice of mailing address (check one) Office___________Home______________

Date of birth___________________________

College/Graduate School, Major, Degree Year

__________________________ ____________________ _______ ____

Psychoanalytic Institute, Dates Attended/Attending, Certification Date

_____________________ _____________________ ______________


If you are certified by the State of Vermont (or other State) as a Psychoanalyst,

Please give License Number_________________________________________



Recommended by_________________________________________________



Please list membership category to which you belong or for which you are

applying (consult Membership Categories list)________________________


Signature______________________________________Date______________


IF YOU ARE A NEW MEMBER, OR MAKING UPDATES OR CORRECTIONS, PLEASE FILL OUT PART II SECTIONS A AND/OR B ON NEXT PAGE AS APPROPRIATE.

SOCIETY OF MODERN PSYCHOANALYSTS

PART II

SECTION A For New Members

Note: Please complete the following and, if necessary, attach additional pages.

Individual Psychoanalyst, No. of Sessions, Dates

___________________________ ____________________ _____________

___________________________ ____________________ _____________

Group Analyst

___________________________ ____________________ _____________

______________________________ ______________________ _______________

Control Analyst

______________________________ ______________________ _______________

______________________________ ______________________ _______________

Clinical Supervisors

______________________________ ______________________ _______________

______________________________ ______________________ _______________


SECTION B, For New Members, Updates and/or Corrections

Please list additional courses, workshops, seminars and other educational experience

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Clinical Experience (private practice, agency, clinic, etc.) and Dates_________________

________________________________________________________________________

________________________________________________________________________
________________________________________________________________________

Treatment Modalities /Area(s) of Specialization _________________________________

________________________________________________________________________

________________________________________________________________________

Foreign Languages___________________________________________________


PART II (Continued)

Please list areas of professional activity in which you apply Modern Psychoanalytic

principles: (teaching, research, administration, music, art, business, other)

________________________________________________________________
________________________________________________________________
Publications (bibliographies may be attached)_________________________________
________________________________________________________________

________________________________________________________________

Membership in professional organizations_______________________________

________________________________________________________________

________________________________________________________________

Optional information: (Foreign languages, additional areas of expertise, honors, awards, etc.) __________________________________________________________________
________________________________________________________________
________________________________________________________________


Signature____________________________________Date________________


Application Fee: $10.00 (first time applicants only)


Annual Dues:

P, PP, GP ………………………………… $50.00

CP, CPmm, CGP, APP, F……………….…$25.00

S……………………………………………$15.00

Please print out application, fill out, enclose check made out to SMP with application and send to:

»SOCIETY OF MODERN PSYCHOANALYSTS

»Susan Jakubowicz, PhD, Chair, Membership Committee
» 16 West 10th Street
» New York, NY 10011

For Administrative Use Only:

Check No._______ Date:__________ Amount:__________ Membership number:___________________

Date Approved:______________________