Licensure and Training Verification - Part 3

This EMDR course is open to those who are taking it as Part 3 of their EMDR Basic Training, as well as to people who have already completed their EMDR Basic Training, and are taking this course as a refresher. In order to provide everyone with the correct certificates at the end of the training, and to provide EMDRIA with an accurate list of those who have completed their Basic Training, we need to know if you are taking the course to complete your Basic Training, or as a refresher. If you are taking the course to complete your Basic Training, we also need you to have your Parnell Institute for EMDR consultant verify by email that you have completed your 10 hours of consultation. You will not receive a certificate of completion for Basic Training until we have this verification.

Name*
First Last
Email*
Emergency Name & Contact Phone Number*
Please list the location and date for the event you are attending.*
Are you taking the course to complete your basic training? In other words, you have completed your required 10 hours of consultation with a Parnell Institute consultant (or will complete them by the training date) and this is the third part of your 3-part training.*
- Yes
- No
Please list your license as it needs to appear on your certificate (exclude your name)
NOTE: Please also ask your PI consultant to send an email to parnellinstitute@gmail.com verifying that you have completed your 10 hours of consultation as soon as you complete those hours. You will not receive a certificate of completion for basic training until we have this verification. You may also not attend the training if you have not completed these hours.
If you are completing this for basic training, please list the name of your PI consultant.
If you are completing this for basic training, have you completed your 10 consultation hours? If not, when do you expect to complete them?*
Are you taking Part 3 as a Refresher course? If so, please submit documentation verifying that you have completed your EMDR Basic Training with an EMDRIA approved trainer.*
- Yes
- No
If yes, please list the name, degree and license number you wish to have on your certificate below.
NOTE: You will need this certificate in the future if you wish to join the Parnell Institute for EMDR and be listed in our Find a Therapist directory.
License Type (Select one)*
- LCSW
- LMFT
- PsyD
- PhD
License Jurisdiction (state, province, or country)*
License Number*
Upload Your Independent Professional License (MUST INCLUDE EXPIRATION DATE)
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
Please upload these items:
1. Copy of your CURRENT license, certification, or the equivalent, as a mental health professional per the guidelines of your state, province, or country.

2. Certificate of completion for Parts 1 & 2.

3. If you are taking this course for certification, upload a copy of verification of your completed 10 hours with a consultant.

If you don't have a digital copy of your license, you may either scan or photograph it. Click here if you need additional instructions.

*Please make sure your file size is no larger than 10MB. If you have problems uploading, be sure to check the size of your files.