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 work with a mentor for more than two years, or to enlist a mentor as a third, etc. year Fellow (all of which are encouraged) we ask you to work out a mutually convenient fee for ongoing, private consultation.

This form is to reserve your space for the 2023-24 cohort of Ongoing Fellows. To complete this form, please click below.

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Last Name *
First Name *
Permanent Email Address in 23/24 *
Please do not give an educational or work email address, as they can become unreliable
Personal Pronouns
Preferred Phone Number *
Alternate Phone Number
(optional)
Mailing Address *
Name of Expected Work Setting or Graduate School in 23/24 *
(If relevant, please include expected graduation date)
Your Geographic Location *
(Please list the city where you will reside during the 2021-22 academic year.  If Chicago, please specify downtown, north side, south side, or west side)
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:

 *
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