Alliance Ambassador ProgramAmbassador Application

Note: Applicants need to have been licensed for at least 10 years and have a deep understanding of psychoanalytic thinking.

Name: Date:

Professional Status:(Check One)

[ ] MA [ ] MS [ ] MSW [ ] RN [ ] ARNP

[ ] MD [ ] PhD [ ] MEd [ ] Other __________

Office Address:

Office Phone #:

Alternate Phone #:

Email Address:

Clinical Specialties/Areas of Expertise

Primary Clinical Specialty:

Secondary Clinical Specialties:

Are you certified/licensed? [ ] Yes [ ] No

If yes, indicate discipline and date of licensure:Education and Training

Undergraduate College or University:

Post Graduate University:

Describe your education and training in psychoanalytic oriented theory and practice:

Alliance Involvement

How long have you been a member of the Alliance?

Describe your participation as an Alliance member:

Professional Development

How long have you incorporated analytic thinking into your clinical work?

Describe your clinical experience working therapeutically with adults, families, and children:

Relate your experience in relation to offering in-services and/or group consultation (e.g. teaching, working with groups, consulting, etc…):

References

List three professional references, including the nature of your relationship, and include their contact information (phone and email):

1.

2.

3.

Other

Do you suffer from a disorder or illness (mental or physical) that would limit or interfere with your ability to provide in-services or consultation? [ ] Yes [ ] No

If yes, explain the circumstances of your situation:

Have you ever been convicted of a felony? [ ] Yes [ ] No

If yes, explain the nature of the charge:

Have you ever been found guilty or pleaded guilty to a misdemeanor directly related to your practice? [ ] Yes [ ] No

If yes, explain the circumstances:

In preparation for the possibility of being an Ambassador

As an Ambassador, would you be willing to share information relating to various Alliance events, educational opportunities, and membership benefits?

[ ] Yes [ ] No

Would you be interested in providing:

[ ] In-services [ ] Group Consultation [ ] Both

Please write a one-paragraph bio to be shared online:

Please list titles and descriptions (2 to 3 sentences each) for 3 or 4 topics you would be interested in presenting in the community:

1.

2.

3.

4.

**Along with this application, please submit a copy of your Liability Insurance, Professional License, and CV/Resume.

I hereby affirm and attest that all statements, answers, and information contained in this application are true to the best of my knowledge, information, and belief. I understand that falsification, misrepresentation, or omission of any fact(s) requested will be sufficient cause for denial of this application and/or subsequent termination of the participating privileges granted upon the basis of the information contained herein.

Signature ____________________________ Date ____________

Please email completed application, current resume, copy of malpractice insurance, and copy of license/registration to current Ambassador Committee Representative or mail to:

NWAPS, 7511 Greenwood Ave N, #407, Seattle, WA 98103