Update Your Professional Information (July 2026) Name(Required) First Last Business Phone(Required)Cell Phone(Required)Email(Required) Is your consultant status with EMDRIA current?(Required) Yes No * To remain a facilitator/consultant, you will need to maintain consultant status with EMDRIA.Would you like to remain listed on our website referral directory and in the manuals?(Required) Yes No Are you still interested in facilitating? Yes No Are you still interested in providing consultation? Yes No If both of these answers are NO, please disregard the following questions and skip to SUBMIT.Please provide your address recognized by the IRS (1099 purposes) Street / Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If you use a different address to receive checks, please provide it here Street / Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your professional liability insurance up to date today? Yes No Date your professional liability insurance renews MM slash DD slash YYYY If we do not already have your current proof of coverage, please email it to Mayra at assist@emdr.com (front page only)Is your professional license up to date today? Yes No Date your professional license renews MM slash DD slash YYYY If we do not already have the current licensure documentation, please email it to Mayra at assist@emdr.com (front page only)We can accommodate only 3 lines, with character limits. Click here to check your referral listing Yes, I have checked and they are correct (skip to SUBMIT) I will update my specialties below We can accommodate only 3 lines, with character limits.Specialty #1Specialty #2Specialty #3Comments:
