EMDR Basic Consultation Information

Name *

First

Last

Email *

Phone Number *

Can this number receive texts? *

Date of Weekend 1 of the EMDR Therapy Basic Training *

Trainees must complete the 10 hours of consultation within 12 months of their initial start date. If it has been more than a year since your Weekend 1 training, please reach out to your training organization to request and extension

HAP Trainee # *

This is a 5 digit number assigned to you by the EMDR Humanitarian Assistance Program – if you were trained by the EMDR Institute, please enter “Institute”

License Information *

If you are independently licensed, please enter your license # and type (LCSW, LMFT, LPC, etc); if you are practicing under a supervisor’s license, please enter their name and license info

State where Licensed *

If outside of the US, enter your country

I'm interested in: *

Group Consultation
Individual Consultation

You may select both