Personal Information Form for the Chicago Center for Psychoanalysis Ongoing Fellowship (Fellows in their 2nd Year or Beyond are Welcome)
Dear Ongoing Fellow,

Thank you for your interest in the Ongoing Fellowship Program at the Chicago Center for Psychoanalysis. Please note that the Fellowship Program provides a mentor for two years. If you wish to continue with a former mentor for an additional year, or to enlist a mentor as a Fourth or Fifh Year Fellow (which we are delighted for you to do), we ask you to work out a mutually convenient fee with that clinician for your consultation with them.

This form is to reserve your space for the 2024-2025 cohort of Ongoing Fellows. To complete this form, please click below.
Sign in to Google to save your progress. Learn more
Last Name *
First Name *
Permanent Email Address in 2024-2025 *

Please use a personal email address that you have kept over time and which is permanent, not an educational or work address.

Personal Pronouns
Preferred Phone Number *
Name of Expected Work Setting or Graduate School in 2024-2025, if known *
(If relevant, please include expected graduation date)
Your Geographic Location *

Will you reside in Chicago in 2024 – 2025, or outside of it.? If in Chicago, please specify the approximate area. Consultation groups will occur in-person for Fellows in the Chicago metropolitan area in 2024 – 2025. Other Fellows will attend groups virtually.

How many years have you been in the Fellowship? *
If you will be a 2nd year Fellow and you and your mentor have opted to continue together, please supply your mentor’s name below.  I will be continuing with my mentor:

If you are a 2nd year Fellow and do not wish to have a mentor, please indicate below:

 *
Required

If you are a 2nd year Fellow and wish a new mentor, please indicate below:

 *
Required

Regardless of your years as a Fellow, please indicate whether you wish to be in a group:

 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Chicago Center for Psychoanalysis. Report Abuse
Google Forms