REGISTRATION

Complete for the EMDR Basic Training 

First Name*

Last Name*

Address *

Address 1

City *

State/Province *

Zip/Postal Code *

Phone *

Email Address *

Message *

Fully Licensed *

License Number*

Reviewing Clinician (Previously Trained) *

Student?:

If yes, name of school and internship location:

Non-Profit *

Date *
Choose the date for which you are registering from drop down menu below.

How did you hear about us?

$250 DEPOSIT REQUIRED TO SECURE TRAINING REGISTRATION

If securing your place in the training within four weeks of start of training, payment in full is required.  No deposit is required to be added to a waitlist.

All registering clinicians must download and complete the Participant Agreement and fax to (303) 694-4060.

PARTICIPANT AGREEMENT

IF YOU ARE A STUDENT OR UNLICENSED PRACTITIONER, PLEASE COMPLETE THE FOLLOWING APPROPRIATE ADDITIONAL FORMS. (Students need to complete each of these forms in addition to general registration. Graduates who are not yet licensed, need only complete the Unlicensed Clinician Enrollment Form in addition to the general registration.)

UNLICENSED CLINICIAN FORM

STUDENT FORM