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Please print form and mail or fax to WSP.
(See mailing address below; fax 202-237-2730).
Name
_____________________________________________ Degree ________________
Major Profession
____________________________________________________________
Mailing Address
_____________________________________________________________
City ____________________________ State __________ Zip Code _______________
Work Phone (____)___________________ Home
Phone (____)_____________________
Fax (____)______________________ Email Address:
______________________________
Please indicate the training program(s)
for which you are applying:
__________________________________________________________________________
O My $50 nonrefundable application fee
(for each program) is enclosed. I understand that, unless
specifically stated, tuition does not include supervision, personal therapy, and/or other
miscellaneous charges.
_________ Total application fee(s)
enclosed
(Make checks payable to Washington
School of Psychiatry.)
O Please bill my credit card for the
total amount indicated above.
O Master Card O VISA
Account Number ______________________________ Expiration Date ______________
Signature ____________________________
(must be provided to charge)
Personal Information:
Years of Experience
in Profession: _______
Personal Individual and/or Group therapy:
Individual: ____ years Group: _____ years
Experience: Attach curriculum vitae and
a brief description of your work and/or mental health related
experience and its duration, indicating any relationship it may
have to this application. Additional information may be required
after review of your application.
Send this completed form with other
materials requested to:
Registrar
Washington School of Psychiatry
5028 Wisconsin Ave., NW, Suite 400
Washington, DC 20016
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