Application for EMDR Therapy Consultation

Name *

Email Address *

Address 1 *

Address 2

City

State *

Zipcode *

Phone Number *

Degree *

License State and Number *

When and where did you receive your Level 1 & 2 EMDR Therapy training? *

Please list any additional EMDR Therapy trainings you have completed:

Please note which group you wish to join the Monday Morning Online Web Group or the Friday Afternoon Towson Group: *

Certification Status *

Please describe your general treatment approach to include other modalities you integrate into your clinical practice. *

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