Application Forms for Psychoanalysts

You may print and keep this checklist as a reminder of what forms you need to file. This is for your reference and should not be submitted with your application forms. You should also keep a copy of all application forms submitted

All applicants for licensure must initially submit Form 1 along with the $371 licensure and first registration fee. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

This form must be submitted directly by the educational institution(s) where you completed your psychoanalytic studies. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section before sending the entire form to your educational institution. Be sure to sign and date item 9 and include any fee required by the institution.
• Section II: The Registrar must complete this section and return both pages of the form in an official school envelope directly to the Office of the Professions at the address at the end of the form. An official transcript is also required if the degree program was not registered by New York State as licensure qualifying at the time you completed the program.

This form must be submitted directly by the educational institution where you completed your master's or higher degree. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section before sending the entire form to your educational institution. Be sure to sign and date item 9 and include any fee required by the institution.
• Section II: The Registrar must complete this section and return both pages of the form in an official school envelope directly to the Office of the Professions at the address at the end of the form.

Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 10.
• Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department. Also, If the certification/verification documentation provided by a U.S. jurisdictions contains the same information requested in the Form 3, completion of a Form 3 for that jurisdiction is not necessary. For certification/verification documentation that does not contain the same information, a Form 3 will need to be completed for that jurisdiction.

*Profession is defined as professional titles licensed under New York State Education Law.

Appendix A Requirements for Supervised Experience - Psychoanalyst

Send this document to the licensed professional(s) who supervised your experience or will supervise your practice under a limited permit and/or the individuals endorsing your application for licensure along with the form you are asking them to complete.

Complete this form and send it to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 9.

This form must be submitted directly by the licensed professional(s) who supervised your experience. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section before giving the entire form and a copy of Appendix A (PDF10 KB) to the licensed professional(s) who supervised your experience. Be sure to sign and date item 9.
• Section II: The licensed professional(s) who supervised your experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

A separate Form 4B must be submitted for each supervised experience you list on the Applicant Experience Record (Form 4).

This form is for applicants seeking licensure in New York State by endorsement of a license to practice Psychoanalysis issued by another jurisdiction. You must have at least 5 years of licensed experience in Psychoanalysis in the 10 year period prior to applying for licensure in New York State.

Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 9.

You must also complete a separate Form 4F for each licensed colleague you list on the Endorsement Applicant Experience Record (Form 4E).

This form is for applicants seeking licensure in New York State by endorsement of a license to practice Psychoanalysis issued by another jurisdiction. You must have at least 5 years of licensed experience in Psychoanalysis in the 10 year period prior to applying for licensure in New York State.

This form must be submitted by the licensed colleague(s) who is attesting to your licensed practice as a Psychoanalyst in another jurisdiction. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section and send the entire form to the licensed colleague who will attest to your experience as a Psychoanalyst in another jurisdiction. Be sure to sign and date item 9.
• Section II: The licensed colleague who will attest to your licensed experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

A separate Form 4F must be submitted for each licensed colleague listed on the Endorsement Applicant Experience Record (Form 4E).

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

• OP can independently verify that the documentation is received directly from the supervisor
• The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
• Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

All applicants for a limited permit must initially submit Form 5 along with the $70 limited permit fee. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit along with your application.

Continuing Your Application If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).
 

This form is not for all applicants. Use this form ONLY if you are applying/have applied for a New York State Limited Permit as a Psychoanalyst online.
 

• Section I: Complete this section.
• Section II: Your supervisor must complete this section before you can submit it to the Office of the Professions at the appropriate address at the end of the form. It is your responsibility to ensure your supervisor fully completes Section II. Failure to complete this form will delay its review.

This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification of child abuse and maltreatment because the nature of your practice excludes contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.

Use this form to apply for the psychoanalysis diagnostic privilege. All applicants must initially submit the Form 1D along with the $175 non-refundable application fee. In order to apply for this qualification, you must have been licensed in New York State as a psychoanalyst.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.
Change Address or Name You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

Change Address or Name You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

ONLY USE THIS FORM to Certify Education Required for the Diagnostic Privilege. Education taken to meet the Continuing Education Requirement of Your Original Mental Health Practitioner License WILL NOT BE ACCEPTED

• Section I: Complete this section before sending the entire form to the institution(s) where you completed program(s) providing you with semester hours or the equivalent required for the diagnostic privilege.
• Section II: The Registrar must complete this section and return both pages of the form in an official school envelope directly to the Office of the Professions at the address at the end of the form. An updated official transcript or marksheet is also required.

• Section I: Complete this section before sending the entire form to the individual who will certify your experience.
• Section II: The individual who will certify your experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form. 

This limited permit authorizes supervised practice while gaining experience to meet the 2000 direct client contact hours required for the diagnostic privilege. This practice must be under the general supervision of an appropriately licensed professional, as determined by the Department. The fee is $70 and is not refundable. You must also submit a Form 5CS-D - Certification of Supervisor for Diagnostic Limited Permit.

Continuing Your Application If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).

This form requires the signature of the NYS professional that is supervising the hours for the diagnostic privilege. It should be submitted with the form 5D application.

• Section I: Complete this section.
• Section II: Your supervisor must complete this section before you can submit it to the Office of the Professions at the appropriate address at the end of the form. It is your responsibility to ensure your supervisor fully completes Section II. Failure to complete this form will delay its review.