EMDR Consultation Documentation Request Form
This form is required before Sam will be able to write a letter of documentation for your consultation hours. Sam aims to complete letters within 30 days of you submitting this form but it may take longer depending on holidays, out of office dates, etc.
Today's Date (dd/mm/yyyy format)
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Name
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First Name
Last Name
Email
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example@example.com
Pronouns
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What credential are you applying for?
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Certificate of basic training
EMDRIA certification
EMDRIA-approved consultant
Dates, duration, and format (individual or group format) of each consultation. Use the structure of these examples: 1/1/25, 2hrs, group format; 1/4/25, 1hr, individual format. **Only include those hours earned towards the sought credential you identified above**
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I attest that the above is true and understand that this letter will be a verification of EMDR consultation hours only and will not include a recommendation for the credential I seek.
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Submit
Should be Empty: