Personal Information Form for the Chicago Center for Psychoanalysis Fellowship - New Applicants
Dear First Time Applicants,

This form is to apply for the 2024-25 cohort.

Please note that your application is not complete until we receive your CV, personal statement, and letters of recommendation at applyfellowship@ccpsa.org and two copies of your personal statement mailed to Nancy Peltzman, LCSW 400 N. Michigan Ave., Suite 1030 Chicago 60611.

Please note also: If you wish to receive an optional Certificate of Attendance from the Fellowship Program for your own use, you must plan to attend at least 7 group meetings. Meetings for first year Fellows take place on weekend dates of the leader’s choosing throughout the year. Reliable attendance at these meetings enables the safety, trust and mutual support that makes vulnerable sharing of counter transference possible during case discussions and allows valuable clinical learning to take place. For this reason, please do not ask to be assigned to a group unless you are prepared to prioritize attendance at a group.
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Applicant's First Name *
Applicant's Last Name *
Applicant's Personal Pronouns
Applicant's Permanent Email Address for 2024-25 *
Please use a personal email you have kept over time. Do you use an educational or work email address.
Preferred Phone Number *
Name of Expected Work Setting or Graduate School in 2024/2025 if known
Applicant's Expected Geographic Location in 2024-2025

Please specify whether you will be residing in Chicago or out of Chicago, and if in Chicago, approximately where.

Name of First Recommender
Email Address of First Recommender
Professional Affiliation of First Recommender
Name of Second Recommender
Email Address of Second Recommender
Professional Affiliation of Second Recommender
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