THE MASTERSON INSTITUTE FOR
PSYCHOANALYTIC PSYCHOTHERAPY
New York San Francisco
The Society of the Masterson Institute
Membership Application
Date: ____________________ Professional Degree: ____________________________ Name: ____________________________________________________________________ Address: ___________________________________________________________________ City: ___________________________________ State: _______ Zip: ________________ Major Professional Activity or Interest: __________________________________________ ____________________________________________________________________________ __________________________________________________________________________ Please indicate if you are interested in: A. Individual Supervision: ____________________________________________________ B. A Study Group: _________________________________________________________ C. Your Leader's Name if you are in a Study Group: ______________________________
Send the completed application with the appropriate fee ($25 for a new member) to:
The Masterson InstituteFor Psychoanalytic Psychotherapy
60 Sutton Place South
New York, NY 10022
212-935-1414 Phone
212-355-5924 Fax
info@mastersoninstitute.org