Psychoanalysis Form 4b - Certification Of Supervised Experience - 2015
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21.
2.
3.
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6.
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The University of the State of New York
Assigned No.
THE STATE EDUCATION DEPARTMENT
Psychoanalyst Form 4B
(From Form 4)
Office of the Professions
Division of Professional Licensing Services
__________
Certification of Supervised Experience
Applicant Instructions
1. Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item
6.
2. Send this entire form and a copy of Appendix A to your supervisor(s) to complete Section II. The supervisor(s) must return both pages
of the form directly to the Office of the Professions at the address at the end of the form. The form must bear an original notarized
signature of the supervisor(s) and date. If additional copies are needed, you may photocopy this form. This form will not be accepted
if returned by the applicant.
Section I: Applicant Information
1
2
Social Security Number
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Name at time of employment (if different from above): _________________________________________________________________
5
Name of supervisor: ___________________________________________________________ Assigned number from Form 4 _______
I practiced Psychoanalysis as defined below:
Psychoanalysis is the observation, description, evaluation, and interpretation of dynamic unconscious mental processes that contribute
to the formation of personality and behavior in order to identify and resolve unconscious psychic problems which affect interpersonal
relationships and emotional development, to facilitate changes in personality and behavior through the use of verbal and nonverbal
cognitive and emotional communication, and to develop adaptive functioning; and the use of assessment instruments and mental health
counseling and psychotherapy to identify, evaluate and treat dysfunctions and disorders for purposes of providing appropriate
psychoanalytic services.
Duration of supervised experience
Date beginning: _______ / ______ / _______
Date ending: _______ / ______ / _______
mo.
day
yr.
mo.
day
yr.
Total hours practicing Psychoanalysis: _________________________.
6
I request and give my permission to the individual listed in item 5 above to complete Section II of this form and mail it to the New York
State Education Department at the address at the end of this form, and to release any other information requested by the State
Education Department in connection with my application for licensure. I also declare and affirm that the statements made in this
application, including accompanying documents, are true, complete and correct. I understand that any false or misleading information in,
or in connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.
_____________________________________________________________________________ Date ________ / _______ / ________
Signature of applicant
mo.
day
yr.
Psychoanalyst Form 4B, Page 1 of 2, Rev. 11/15
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