MASSACHUSETTS INSTITUTE FOR PSYCHOANALYSIS
POSTGRADUATE FELLOWSHIP PROGRAM
APPLICATION FORM

NAME_____________________________________________   DATE____________________

ADDRESS____________________________________________________________________

EMAIL__________________________________    FAX (    ) _________________________

HOME PHONE (    ) _________________   WORK PHONE (    ) _____________________

Statement of interest. Please describe your interest in psychoanalytic psychotherapy and what you hope to gain from the fellowship program. Use additional space as needed.