The Baltimore Psychotherapy Institute Application Form

Psychotherapy Certificate Program

Name__________________________________  Degree________

Profession_____________________________________________

Mailing Address________________________________________

City_____________  State_______  Zip Code_________________

Work Phone (___)_____________  Home Phone (___)_________

Email Address_____________________

A nonrefundable application fee of $35 is required with each application.  This fee will be applied to tuition for the program if the candidate is accepted.  Please make checks payable to The Baltimore Psychotherapy Institute.

Please include the following with your application:

-A CV or resume that details your general professional experience as well as your clinical experience.

-A brief personal statement explaining what you hope to gain from the certificate program in psychotherapy.

-Two (2) professional references.

An interview is required for admission, and will be scheduled after your application is reviewed.

 Please mail your completed application to: BPI, 711 W. 40^th Street Ste. 456, Baltimore MD 21211-2120