Application For EMDR 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 *

Already EMDRIA Certified

Hoping to earn hours towards certification

Not Certified, but not interested in earning hours at this time

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

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