EMDR Basic Training Registration Full Application

EMDR Basic Training Registration Application

All applicants must complete this section. If you would like to fill out part of the form now and come back to finish or upload documents you may do so but you MUST input your email near the top of this form before saving.
To assure prompt processing of your registration application, please include the following items:

1. A copy of your CV or resume

2. A copy of your professional license

a. For non-licensed and pre-licensed professionals, please include the additional information outlined under the Non-Licensed and Pre-licensed professionals section.

3. Complete any additional sections of this form that are applicable to you
Name

First NameLast Name
Email to be used for correspondence throughout the training*
example@example.com
Degree
Professional License
State and License Registration Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone
Fax
Home Telephone (optional)
Cell Phone (optional)
How did you learn about our training? (Check all that apply)

EMDR-trained colleagueEMDRIA list of training providersWeb search (indicate search engine if known, e.g. Google, Yahoo.)Email noticeAttending one of our presentationsOther
Upload a copy of your CV or resume

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Upload a copy of your professional license

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Non-licensed and Pre-licensed Professionals

This section is for non-licensed and provisionally licensed clinicians only. Skip if not applicable.
With the application package, non-licensed and provisionally licensed clinicians must provide the below information as evidence of:

1) meeting EMDRIA educational qualifications;

2) having an appropriate supervised clinical setting; and

3) being in the process of moving toward licensure for independent practice.

We will not be able to review your application without submission of these materials.
1. Upload a letter describing your current practice situation that addresses the following:

a) Your current practice setting.

b) The kinds of clinical diagnoses/presentation and population with whom you currently work.

c) The number of clients you see in on-going psychotherapy.

d) The frequency of therapy sessions with these clients.

e) The therapy methods or approaches you currently use.

f) The license you are pursuing.

g) The anticipated or estimated date when you plan to achieve independent licensure.
Upload letter:

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2. A letter from your licensed clinical supervisor who is providing your direct licensure supervision. (If your clinical supervisor is not your management supervisor, you must also provide a letter from your management supervisor.)
Upload Letter from licensed clinical supervisor:

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Note: Mental Health Clinicians who have a master's degree in one of the following fields must submit their graduate transcript to EMDRIA to determine their eligibility: Art Therapy, Christian/Pastoral Counseling, Drug/Alcohol Counseling, and Music Therapy. If EMDRIA approves your education and licensure status, please submit approval documentation from EMDRIA with your application.
Agency Eligibility and Discount

Skip if not applicable.
To request a non-profit agency discount please provide a letter on agency stationary from your employer confirming full time employment.
Upload letter:

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Participants Name

First NameLast Name
Participant's Job Title (including hours working with the agency)
Name of Agency
Clinical Supervisor's Name and Title
Clinical Supervisor's Phone Number
Please enter a valid phone number.
Management Supervisor's Name and Title
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Phone Number
Please enter a valid phone number.
Please describe your agency; population/s served, therapeutic modalities used currently, and any EMDR therapy support that currently exists within the agency.
For all applicants:

All applicants must sign and date.
Participants Signature:*

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Date*

MonthDayYear
Date
If you would like to fill out part of the form and come back to finish or upload documents at a later time you may do so but you MUST input your email near the top of the form before you can save the form.
Should be Empty:

EMDR Basic Training Registration Application

Non-licensed and Pre-licensed Professionals

Agency Eligibility and Discount

For all applicants: