Intern Member Application


  • Submit completed application form, two essays and proof of successful completion of coursework and confirmation of readiness for Internship to IPSA Membership Committee (
  • Submit a $75.00 check payable to the IPSA Treasurer for your first year of membership. Membership in IPSA must be maintained on an annual basis. 

Application for IPSA Intern Membership

 Name  ____________________________________________________________                        Date______________________

Mailing Address                                       _________________________________________________________________                       
Email Address                                                                                                                                                                                                             ___________  _

Personal Contact Phone #                                                                                                  Referral/ Business Phone#                                                                      
Type of clients you are most interested in serving (please list any special populations, genders, or presenting problems you feel most suited to work with during Internship)



I ,                                                                                    ( print your name) , declare that I have read and understand the IPSA Code of Ethics. I pledge to accurately identify myself as an Intern Surrogate Partner until I am certified as a professional surrogate partner; to only work with clients who are concurrently seeing a therapist who is willing to supervise my internship; to discuss all referrals with the IPSA training staff and my mentor(s) prior to accepting any new cases; and to endeavor to honor the IPSA Code of Ethics, to safe guard clients’ well being and to reflect positively on the field of surrogate partners, especially when representing myself as a Surrogate Partner and/or as an IPSA member.

Signature__________________________________________________________Date   _____________________

Two Essays

In your own words, in two separate essaysanswer the following questions:

  • What is Surrogate Partner Therapy?
  • What is the role of the Surrogate Partner?  For what is the Surrogate Partner responsible?

Note about these essays:  The original thinking and writing required for these two essays will help you develop skills, ideas and materials that you will need for marketing your practice and answering questions from referring therapists, prospective clients, friends, and family.  Although the concepts and your capacity for articulation will evolve as you gain experience in the field, IPSA wants essays that reflect your current point of view about Surrogate Partner Therapy and the role of a Surrogate Partner. Developing your ability to talk about your work is a very important part of transitioning from trainee to professional.

Letter of Recommendation for Internship

A Letter of Recommendation for Internship provided by IPSA training staff at the end of successful completion of the first phase of training (the coursework) should be submitted along with the application for IPSA Intern Membership. Alternatively, an Intern may request the IPSA training staff contact the IPSA membership committee directly to confirm their successful completion of the first phase of training and readiness for Internship.

Membership Dues

Send a $75.00 check or money order payable to IPSA or pay through PayPal. (Request PayPal information and/or the treasurer’s mailing address from the IPSA Treasurer.)