Personal Information Form for the Chicago Center for Psychoanalysis Fellowship

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Dear First Time Applicants,

Thank you for your interest in the Fellowship Program at the Chicago Center for Psychoanalysis.

This form is to apply for the 2021-22 cohort.

Please note that your application is not complete until we receive your CV, personal statement, and letters of recommendation at applyfellowship@ccpsa.org.

Applicant's First Name *

Applicant's Last Name *

Applicant's Personal Pronouns

Applicant's Email Address *

Preferred Phone Number *

Alternate Phone Number

(optional)

Applicant's Mailing Address *

Name of Current Work Setting or Graduate School *

(If relevant, please include expected graduation date)

Applicant's 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.)

Applicant's Attendance Preference *

Option 1 - I prefer to attend events in person (when safety makes the option available)

Option 2 - I prefer to participate via Zoom, but could attend in person

Option 3 - I am out of the Chicago area and need to participate via Zoom

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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