Honorific
== select == Mr. Ms. Miss Mrs. Dr.

First Name

Last Name

Title/Position

Organization

Gender
== select == Male Female Non-binary Prefer not to indicate

Website

Birthdate
(month) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec , 

Birthplace

Are you a member of the APsaA?
 Y    N

Designation
 Candidate Psychoanalyst  
 Clinical Psychologist  
 Clinical Social Worker  
 Educational Psychologist  
 Graduate Psychoanalyst  
 Graduate Psychoanalyst (retired)  
 Graduate Psychoanalytic Psychotherapist  
 Graduate Psychoanalytic Psychotherapist (retired)  
 Licensed Clinical Social Worker  
 Psychiatrist  
 Psychiatrist (retired)  
 Research Candidate in Psychoanalysis  
 Research Graduate in Psychoanalysis  
 Student Psychoanalytic Psychotherapist  
 Other  

Ethnicity
 American Indian/Alaska Native  
 Asian  
 Black/African American  
 Caucasian  
 Hispanic/Latin  
 Native Hawaiian or Other Pacific Islander  
 Prefer not to indicate  

Languages Spoken
 Arabic  
 French  
 German  
 Italian  
 Spanish  
 Chinese  
 Russian  
 Hindi  
 Polish  
 ASL  

Organization Profile

Contact Information

Address

City

State/Prov
== select == ==USA== AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY ==Canada== AB BC MB NB NL NS NT NU ON PE QC SK YT ==Outside Canada/US==

Country
== select == Canada United States --- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe

Zip Code

Phone

E-mail

Accepts Insurance
 Y    N

Spouse Name

Take Child Patients?
 Y    N

Education

Name of Psychoanalytic Training Program

Psychoanalytic Training Program Graduation Date

Degree
 ABPP  
 BA  
 BCD-P  
 CGP  
 DNP  
 DO  
 DSW  
 EdD  
 FABP  
 JD  
 LCPC  
 LCSW  
 LCSW-C  
 LGSW  
 LICSW  
 LPC  
 M.A.Ed.  
 M.Ed  
 M.Med  
 M.Phil  
 M.Sc  
 MA  
 MD  
 MFA  
 MPH  
 MS  
 MSN  
 MSS  
 MSW  
 PhD  
 PMHCNS-BC  
 PsyD  
 RN  
 STA  
 Other or None  

Specialty
 Psychoanalysis and Psychotherapy with Adults  
 Psychoanalysis and Psychotherapy with Adolescents  
 Psychoanalysis and Psychotherapy with Children  
 Psychotherapy with Adults  
 Psychotherapy with Adolescents  
 Psychotherapy with Children  
 Psychological Testing  
 Neuropsychological Testing  
 Medication consultation  
 General Psychiatry  
 Forensic Psychiatry  
 Licensed Psychologist  
 Licensed Psychiatrist  
 Licensed Clinical Social Worker  
 Licensed Professional Counselor  
 Couple Therapy  
 Other  

Specialty Other Explained

Corresponding Institute

Privacy Information

Who can view your profile?
 public
 members only
 administrators only

Do you consent to receive email communications from us?
 Y    N

Do you want to display your email on your profile?
 Y    N

Enter the text you see:

New image ↻
Can't see the image?