User Test

Member Enrollment Form For Test

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 (This will be your user ID for all future logins)(Required)

Enter Email Confirm Email

Password(Required)

Enter Password Confirm Password

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)

Are you Licensed(Required)

specify license (like LPC, LMFT, LCSW, Psychologist, etc..)

Are currently a Student in a Graduate Program?

You are not eligible to register for this training at this time. please contact Dr.Chandra at 719-761-4444 for more information

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

You are eligible to register for the training.

You are not yet Qualified to take this training. Contact Dr.Chandra at +1 7197614444

If you are Student/Alumni/Faculty of Colorado Christian University, use discount code “universitysponsored” to get $200 discount Or If you are a Student of any other Institution/University, use the discount code “student” to get $100 discount

Have you completed EMDR International Association Approved Basic Training?(Required)

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

If eligible, choose only one Discount

Discount Coupon Name:- student

Discount Coupon Name:- nonprofit

Discount Coupon Name:- universitysponsored