Unlicensed Clinician Agreement

 Unlicensed clinicians must meet EMDRIA educational qualifications such that they have an appropriate supervised clinical setting and are in the process of moving  toward licensure for independent practice. 

Name *
Name
Describe your current practice setting:
Describe the kinds of clinical problems and clients with whom you currently work:
State the number of clients you see in on-going psychotherapy:
What license you are pursuing?
The anticipated or estimated date when you plan to achieve licensure?
Name and license number of your Supervisor:
By typing my name below, I confirm the above information is correct and true: