Update Therapist Directory

Member Enrollment Form

This form is used to enroll members to the website

Name (Required)

First Last

Address (Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Email (Required)

Enter Email Confirm Email

Personal Phone (Required)

Institution/Practice Name

Do you wish to be listed in the directory?

Business Email

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Business Phone

Do you have a Graduate Degree in the field of Mental Health? (Required)

Specify the Degree (like MA, MS, MSW, Ph.D, Psy.D, etc..) (Required)

If you are licensed to practice, specify license and state of issue (like LPC, LMFT, LCSW, Psychologist, etc..) (Required)

Have you completed core course requirements and eligible to participate in graduate internship or currently in one?

Have you completed EMDR International Association Approved Basic Training?

If YES, Where did you complete your Basic EMDR Training?

Phone

This field is for validation purposes and should be left unchanged.