Apply

To apply to our APP program, you may complete the application below and submit it online, or download a copy here and mail it to:

APP — NC3P
c/o Tennyson Dodd
524 Inwood Drive
Nashville, TN 37211

For more information, please contact any of the Co-Directors:

Dr. Jeff Binder 615-358-8073

Tennyson Dodd 615-358-8073

Advanced Psychodynamic Psychotherapy Application

Date(Required)

All fields are required!

Name(Required)

First Last

Work Address(Required)

Street Address City State ZIP Code

Home Address(Required)

Street Address City State ZIP Code

Work Phone(Required)

Home Phone

Mobile Phone(Required)

Email(Required)

Date and Place of Birth(Required)

Citizenship(Required)

Educational Background (College & Graduate Programs)(Required)

Dates

Degree

Institution

Please click the plus sign at the end of the row to add up to 4 additional lines.

Current Work Experience

Dates

Employer

Position

Description

Please click the plus sign at the end of the row to add up to 2 additional lines.

Previous Work Experience

Dates

Employer

Position

Description

Please click the plus sign at the end of the row to add up to 2 additional lines.

Supervision or Consultation (current and previous)(Required)

Supervisor/Consultant

Dates

Frequency

Please click the plus sign at the end of the row to add up to 1 additional lines.

Personal Analysis or Therapy (Your therapist will not be contacted.)

Therapist or Analyst

Session Frequency

Dates: From/To

Approximate Total # of Sessions

Please click the plus sign at the end of the row to add up to an additional line.

Describe any special circumstances that might affect or complicate your participation in this program:(Required)

What are your goals in undertaking this program?(Required)

Describe your experience doing psychotherapy or counseling. Please include specific information about the type of treatment offered, the number of patients the frequency and length of sessions. This may be included as an additional attachment to the application.(Required)

References - Please list two references who know you and your work as a psychotherapist. Your signature on this application form indicates that you give your permission for us to contact the references listed below.(Required)

Name

Address

Please click the plus sign at the end of the row to add an additional line.

There is a $60 application fee. Please use the button below to complete the payment. I understand that my application and progress within this program will be subject to assessment by the instructors in the program and agree to abide by this assessment.

Signature(Required)

APP Appication Fee

Price:

Total

Credit Card

Card Details

Cardholder Name