Pittsburgh Psychoanalytic Center



Pittsburgh Psychoanalytic Center

A Comprehensive Survey of the Complete Psychological Works of Sigmund Freud

Application Form

Name: ___________________________________________________

Business Address: ___________________________________________________

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Business Phone: ___________________________________________________

Home Address: ___________________________________________________

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Home Phone: ___________________________________________________

Email Address: ___________________________________________________

Please indicate your preferred mailing address and phone number above with a star *

Please include the following with your application:

1. Non-refundable application fee of $100. (Checks may be made payable to the Pittsburgh Psychoanalytic Center.) *If accepted to the program, social workers who desire continuing education credits will be assessed a $25 certification fee. The remaining payment for the course may be paid at the first session, or in payments at subsequent sessions.

2. So that we can best craft the discussion will you please provide a little bit about your interest, your knowledge of the works we will be reading and what you hope to gain from participating in the sessions.

3. Please provide a brief introduction to your educational/professional background:

How did you hear about this course?

Email Postcard Flyer Website Online Calendar

Other: _______________________________________________________

Continuing Education Credits: Maximum 40 if all sessions are attended

Check if you are applying for CE credits:

_____ Physician _____ Psychologist _____Social Worker/LPC/MFT

Continuing Medical Education Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Psychoanalytic Association and Pittsburgh Psychoanalytic Center. The American Psychoanalytic Association is

accredited by the ACCME to provide continuing medical education for physicians. The American Psychoanalytic Association designates this Live Activity for a maximum number of 40 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

IMPORTANT DISCLOSURE INFORMATION FOR ALL LEARNERS:

None of the planners and presenters of this CME program have any relevant financial relationships to disclose.

APA-American Psychological Association Statement:

Pittsburgh Psychoanalytic Center is approved by the American Psychological Association to sponsor continuing education for psychologists. The Pittsburgh Psychoanalytic Center maintains responsibility for the program and its content.

The Pennsylvania Board of Social Work approves of credits issued by APA sponsors. Therefore, the Pittsburgh Psychoanalytic Center is able to offer continuing education credits to social workers and counselors per Section 49.36(a) (6) ix) of the regulations at the time of offering

Statement Regarding the Intent of This Educational Opportunity

I also understand that this program is not being represented as training for practice in psychoanalysis. Therefore, upon completing the course requirements, I will not represent myself as being a psychoanalyst or a graduate of the Pittsburgh Psychoanalytic Center’s Training Program in Psychoanalysis.

In addition, I understand and agree that consideration of this application by the Pittsburgh Psychoanalytic Center and my participation in the Program is at the sole discretion of the Center, and under no circumstances will the Center, its officers, trustees, faculty, employees or members be liable to me by reason of any action or inaction in relation thereto.

Signature _______________________________________ Date _____________

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Please return your completed application to:

Pittsburgh Psychoanalytic Center

401 Shady Ave., Suite B-101

Pittsburgh, PA 15206

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