CHD Student Matriculation 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 MATRICULATION FORM

Please submit this completed form and your check for $65 to the above address—Attn. Registrar.

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):

_________________________________________________________________________________________________
DEGREE/MAJOR YEAR SCHOOL

_________________________________________________________________________________________________
DEGREE/MAJOR YEAR SCHOOL

_________________________________________________________________________________________________
DEGREE/MAJOR YEAR SCHOOL

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 Hours_____	Dates ________________
(Supervisors name)		(from - to)

Please describe your goals in seeking psychoanalytic training at CHD:

___________________________________________________________________________________________

Pertinent Life Experience:
___________________________________________________________________________________________

___________________________________________________________________________________________

Signature of Applicant:______________________________________ Date___________________