Application Are you or have you ever been a member of EMDR? If so, please fill the renewal form instead. Membership* Professional Retired Student Associate Contact InfoName* First Last Mailing Address* Street Address Address Line 2 City Province Postal Code Phone*Email* Enter Email Confirm Email Professional InformationMental Health Degree* Name of Institution* Address of Institution* DegreeMax. file size: 10 MB.Profession* Title Granted By The Regulatory Body* Professional Regulatory Body* Registration #* Registering Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonCertificate of Membership with the Regulatory BodyMax. file size: 10 MB.I confirm that while being a member of EMDR Canada I will:*- Hold a membership in good standing with my regulatory body -Hold professional liability insurance I declare that these above conditions will continue to be met during the time I am a member of EMDR Canada. EMDR TrainingEMDR Designation*If you would like to add another designation, please contact us after completing this form. EMDR Trained Therapist EMDRIA Certified Therapist Consultant in Training EMDRIA Approved Consultant in EMDR EMDRIA Approved Trainer EMDR Basic Training Date* MM slash DD slash YYYY MembershipMembers Directory* List me in the directory Do not list me in the directory Keep me informed of future workshops and trainings* Yes No Journal EMDR Practice & Research(Online journal is free) Printed journal Preferred Language* English Français REGIONAL COORDINATORS PROJECTThe Regional Coordinators are volunteers for EMDR Canada who organize group meetings of trained EMDR therapists for the purpose of sharing information and supporting each other. If you are interested in becoming a Regional Coordinator, a Board Member will contact you. Yes, I am interested in becoming a regional coordinator in my area. No thanks, I am not interested in becoming or continuing as a regional coordinator. Member DirectoryThe information you provide here will be displayed in the member directory. Only fields marked with an asterisk are required.Street Address Apt/Suite/Office City* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code* Population served* Children Adolescents Adults Seniors Required Qualifying ProofStudents: Please provide a copy of full-time student registration. All other members please provide a copy of your EMDR L2 Training Certificate.I will provide this via:* Upload Fax Mail EMDR L2 Training Certificate*Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.Registration Education Institute*(full time)Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.Fax Instructions 418-599-2401Mailing Instructions EMDR Canada CP 115, Ste-Agathe-de-Lotbinière PO, QC G0S 2A0lLoginUsername* Password* Enter Password Confirm Password Strength indicator PaymentTotal $ 0.00 CAD Payment Method* Cheque or Money Order Credit Card Mailing Instructions EMDR Canada CP 115, Ste-Agathe-de-Lotbinière PO, QC G0S 2A0 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.
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