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The International Class
Application Cover Sheet
Activities
Two residencies at the Institute in New York City: 12 days in September-October; 12 days in March-April
Four-five online seminars in between residencies
Supervision on practice or project as requested
Fee
$3200
Not Included
Transportation costs to NY and food and housing while in NY are the responsibility of the applicant. In many cases, we can find living accommodations upon request.
Signature ____________________________________________
Date ________________________________
Applications can be sent to Lois Holzman at lholzman@eastsideinstitute.org or East Side Institute, 104-106 S. Oxford Street, Brooklyn, NY 11217
EAST SIDE INSTITUTE FOR GROUP AND SHORT TERM PSYCHOTHERAPY
The International Class Application
Date______________________
Name ___________________________________________________________
Address________________________________________________________
City___________________________________State___________________
Zip/Postal Code____________Country___________________________
Telephone_________________________Fax____________________________
Email___________________________________________________________
EDUCATION (BACHELOR’S AND ABOVE)
Institution______________________________________________________________
Years Attended_____________Degree____________________________________________
Department and/or Concentration___________________________________________
Institution______________________________________________________________
Years Attended_____________Degree____________________________________________
Department and/or Concentration___________________________________________
Institution______________________________________________________________
Years Attended_____________Degree____________________________________________
Department and/or Concentration___________________________________________
PROFESSIONAL EXPERIENCE (INCLUDING INTERNSHIPS)
Institution_____________________________________________________
Title/Position__________________________________________________
Dates__________________________
Institution_____________________________________________________
Title/Position__________________________________________________
Dates__________________________
Institution_____________________________________________________
Title/Position__________________________________________________
Dates__________________________
PROFESSIONAL INTERESTS
In an essay of 500-1000 words, describe your experience and interests and how they led you to want to study at the Institute. Include specifics about the Institute’s methodology that attract you and why.