CHD Student Application Form

CENTER FOR HUMAN DEVELOPMENT

Executive Directors: Dr. Susan Jakubowicz and Dr. Lynne Sacher
Administrative Offices (mailing address): 16-21 Split Rock Road +++ Fair Lawn, NJ 07410
Executive Offices: 1225 Park Avenue, Suite 1A +++ New York, NY 10128
Telephone: (212) 642-6303 +++ E-mail: ctrhumandev@aol.com

STUDENT APPLICATION FORM

*Please submit this completed form and your check for $65.00 to the Administrative Offices—Attn. Registrar—at the above address. Please also have official transcripts of your Bachelor’s, Master’s, doctoral (if applicable) studies and previous psychoanalytic institute work sent to the CHD Administrative Office immediately. They must be on file prior to admission to the Program.

Name:____________________________________________
(Please print) LAST, FIRST, TITLE

Address:_________________________________________________
NUMBER AND STREET (APT #)

_______________________________________________________________
CITY, STATE, ZIP CODE

______________________________/_________________________________
Daytime Telephone / E-mail:

_______________________________/________________________________
Present Occupation / Date of Birth:

Educational Background (most recent first):

________________________________/_____________/_________________________________
BACCALAUREATE DEGREE/MAJOR, YEAR, SCHOOL

________________________________/_____________/_________________________________
MASTER’S DEGREE/SUBJECT, YEAR, SCHOOL

________________________________/_____________/_________________________________
DOCTORAL DEGREE(IF APPLICABLE)/SUBJECT, YEAR, SCHOOL

**Remember to send transcripts of all previous education

Treatment History

Current Analyst:_____________________________________	#of Sessions:___________	Dates:_________________
		(from - to)
Previous Analyst:_____________________________________	#of Sessions:___________	Dates:__________________
		(from - to)
Group Analyst:______________________________________	#of Sessions:___________	Dates:__________________
		(from - to)

Previous Psychoanalytic Training

Institute Courses:_____________________________________/_________________________________________

(Institute name / Course titles)


Supervision:_____________________________________	#of Hrs:___________	Dates:__________________
(Supervisors name)		(from - to)

**Send Transcripts of all institute training (if applicable)

Please describe your goals in seeking psychoanalytic training at CHD

____________________________________________________________________________________

Pertinent Life Experience
____________________________________________________________________________________

____________________________________________________________________________________

Referred by:__________________________________ Affiliation: ________________________________

Signature of Applicant:______________________________________ Date:________________________