EMDR Consultation Request
Please complete this form and we will be in touch for next steps for EMDR consultation. I'm looking forward to hearing from you! ~ Mandy Wannarka, LICSW, EMDRIA Approved Consultant
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Name (First and Last) * *
Email * *
Address * *
Phone Number * *
Degree * *
License State and Number * *
When, where, and with whom did you receive your Level 1 & 2 EMDR Therapy Basic Training? * *
Please list any additional EMDR therapy trainings you have completed: *
Please describe your general treatment approach to include other modalities you integrate into your clinical practice. *
Our clinic is committed to anti-racism. What experience do you have with working on being anti-racist professionally or personally? *
What are you hoping to learn from this consultation group? *
EMDR Certification Status *
Which consultation group are you interested in? *
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