Review Registration Information and Sign the Participant's Agreement - EMDR Institute - EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY

Please review the registration information that we have on file.

Please correct any information below so that it is accurate. It is critical that we have a working cell phone and deliverable physical mailing address.

This field is read-only. To update please contact assist@emdr.com

Legal Name That You Will Use to Sign the Participants Agreement(Required)

First Last

Legal name will be printed on certificates and used for all communication.

Cell Phone(Required)

This needs to be a US/Canada cell phone number that can receive text messages and will be used during training.

Work Phone(Required)

Preferred Pronouns

SMS Consent(Required)

I consent to receive important event notifications leading up to the training via a text message.

I choose to opt out of text messages and acknowledge that I might miss important last-minute updates.

Mailing Address to Receive Training Manuals

Street Address or PO Box(Required)

Street Address Line 2

City(Required)

State / Province / Region(Required)

Zip / Postal Code(Required)

Country(Required)

Are you licensed(Required)

Yes

Professional License Type(Required)

License number(Required)

If you are Intern / Student / Associate / Provisional please put N/A in this field. If "Other" please provide license type.

International Registrants - Please describe your licensure(Required)

Clinical Specialty - Population

Clinical Specialty - Diagnoses

Clinical Specialty - Symptoms

Review Registration Information and Sign the Participant’s Agreement

Please review the registration information that we have on file.

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Francine Shapiro, PhD

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