Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Can this number receive texts? *YesNoDate of Part 1 of the EMDR Therapy Basic Training *Trainees must complete the 10 hours of foundational consultation within 12 months of their initial start date. If it has been more than a year since your Part 1 training, please reach out to your training organization to request an extensionHave you completed Part 2 of the EMDR Therapy Basic Training? *YesNo, but I have it scheduledNo, and I do not have it scheduledDate of Part 2 of the EMDR Therapy Basic Training (leave blank if not yet scheduled)Knowing this date helps ensure we pace your consultation sessions correctly, as there are strict limits on how many hours can be logged before Part 2Have you received foundational (Basic) EMDR consultation from any other consultants? *No, I am just starting consultationYes, I have used one other consultantYes, I have used two or more other consultantsTrainees are limited to obtaining consultation from a maximum of two consultants total across the 10 hours of foundational (Basic) consultation. If your circumstances do not allow you to continue working with your prior consultants, please reach out to your training organization to request an exceptionHAP 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 ConsultationIndividual ConsultationYou may select both Submit