RYA Advance Reg form June 2021

Advanced EMDR and Play Therapy with Children and Families

Facilitator: Renee Yoelin-Allen LCSW RPT-S

Registration Form

Trainee Name

Mailing Address, City, State, & Zip Code (this will be the one EMDRIA keeps on file)

Phone #

Email

example@example.com

Professional Degree(s)

License(s) & #'s

Date and location of BASIC EMDR training must be completed by the date of this training.

Date

I certify that by the time of this training, I have met the prerequisite for this Advance EMDR training by completing the Basic EMRD training that included 50 hours of training and 10 hours consultation.

Clear

Please initial how you are completing payment- $175 full price.

If utilizing the early registration discount- paid on or before May 27th 2021- - $10 discount- Total $165. Early discount must repaid with Venmo or mailed check, received on or before May 27th, 2021

Form of payment:

Venmo to Renee Yoelin-Allen (preferred) Mail a check to Renee Yoelin-Allen at 5555 Erindale Dr. Suite 203 Colorado Springs, CO 80918 delivered before May 27th 2021. On line via Paypal at ryaplaytherapy.com. Click "payment options."

What type of credit would you like to receive from this training?

EMDRIA - 7 credits offered Assoc. for Play Therapy (APT) 6 credits offered. Completion of a post-test is required. Both APT and EMDRIA credits option 2

upload is optional- BASIC EMDR training certificate - 50 hours of training and 20 hours of consultation

Copy of State License or registration as an unlicensed therapist in your state.