Application for EMDR Consult Groups

EMDR Therapy Consultation Application

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Degree

License State and Number

When, where, and with whom did you receive your Level 1 & 2 EMDR Therapy Basic Training?

Please list any additional EMDR therapy trainings you have completed:

Please describe your general treatment approach to include other modalities you integrate into your clinical practice.

Have you received any training in antiracism and/or cultural humility with historically marginalized and oppressed populations?

What are you hoping to learn from this consultation group?

Certification Status

Already EMDRIA Certified

Hoping to earn hours toward certification

Not Certified, but not interested in earning hours at this time

Which kind of consultation are you interested in?

General EMDR Consult Group: Fridays, 10am-12pm

EMDR for PMH Providers Group: Mondays, 10am-12pm

Individual Consultation

A limited number of partial scholarships are available for qualified applicants who have a financial need and work with historically marginalized and oppressed client populations. Would you like an additional scholarship application sent to you?

Yes