EMDR Basic Training Intake Form

Welcome to EMDR Basic Training

Before your training begins, EMDRIA requires all participants to verify their eligibility by submitting the appropriate documentation.

Instructions:

Upload the required documents based on your professional status.
Ensure all documents are clear and legible.
If your submission is incomplete, you will receive an email requesting resubmission.

Required Documentation by Licensing Status

To participate in EMDR Basic Training, EMDRIA requires documentation to confirm eligibility. Please provide the following based on your current status:

Licensed Mental Health Professionals

Copy of your current mental health license

Pre-Licensed / Provisionally Licensed Professionals

Copy of your graduate degree in a mental health field
Proof of an active supervision agreement (e.g., supervisor letter, contract, or verification form)
Supervisor’s full name, license number, and contact information

Graduate Students

Letter from a faculty member or supervisor confirming:
- Enrollment in a practicum or internship in a mental health discipline
- Your role in providing direct mental health services
- Supervisor’s name, license, and credentials

You will be prompted to upload your documentation later in the form.

First Name *

Last Name *

Email *

Phone *

License Number *

Supervisor (if applicable) *

License Status *

Address

Street Address

City

State

Country

Postal Code

Current professional status:

This selection will determine which documentation must be submitted to ensure your eligibility to participate in EMDR Basic Training.

Upload the following documents: a signed letter from your faculty or supervisor confirming your enrollment in a practicum/internship and your role in providing mental health servicesThe following file types are accepted (PDF, JPG, PNG, DOC)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

I was able to successfully upload all of the documents above. *

Yes

No, please email me so I can respond with my required documentation.

Notes

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Terms and Condition