Eye Movement Desensitization Reprocessing Therapy (EMDR) Rostering Application - Treatment Collaborative for Traumatized Youth

General Information

First Name*

Last Name*

Degree (ex. M.S., M.E.d)*

License (ex. LPC, LPCC)*

Personal Email Address*

Professional Email Address*

Personal Phone Number*

Agency Phone Number*

Agency Name*

Agency Address*

Agency City*

Agency State*

Agency ZIP Code*

Agency County*

Agency Type (ex. residential, inpatient, outpatient)*

Agency Website*

Treatment Information

License Information

License Number*

License State*

Years of experience practicing in the mental health field*

Have you participated in and completed an EMDR training program?*

Yes
No

Date of training*

Trainer name*

Trainer organization*

EMDR training proof of completion*

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Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Approximately how many sessions have you conducted where EMDR was utilized?

Have you participated in and completed ongoing consultation from an EMDRIA (EMDR internation association) approved consultant as part of your EMDR training?*

Yes
No

Date of ongoing consultation*

Name of approved consultant*

Consultant organization*

Proof of ongoing EMDR consultation*

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Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Since your initial EMDR training completion, have you completed continuing education on EMDR?*

Yes
No

Additional File Uploads (optional)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

EMDR national certification certificate, proof of certification renewal if more than 2 years since trainings, continuing education certificates on EMDR in years since original EMDR training

Message (Optional)

Phone

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