Forms

Application for Certification in AF-EMDR

Please complete the form below.

Name*
First Middle Initial/Name Last
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(not publicized)
Best Contact Phone Number*
Best email to reach you. (This must correspond to an email already associated with your Parnell Institute account)*
Website
Highest Degree Obtained (MA, MSW, Ph.D., M.D., etc.)*
Institution where received*
Date received*
Date of completion of Parnell EMDR Basic Training Parts 1-3 including 10 hours of consultation (now known as Parnell Institute Attachment-Focused EMDR Basic Training as of January 1, 2022).*
Attach copy of Parnell EMDR Basic Training Parts 1-3 including 10 hours of consultation (now known as Parnell Institute Attachment-Focused EMDR Basic Training as of January 1, 2022) Certificate of Completion with a Parnell Institute Trainer*
Max. file size: 256 MB.
Licensed Mental Health Field of Practice:*
State & Country Issued:*
Attach copy of current license to practice independently in State or Province.
Max. file size: 256 MB.
Do you have at least two years of clinical practice post-licensure and two years post Parnell EMDR Basic Training Parts 1-3 including 10 hours of consultation (now known as Parnell Institute Attachment-Focused EMDR Basic Training as of January 1, 2022) in your field of license/ certification/registration as a mental health professional?*
Have you conducted at least 50 AF-EMDR processing sessions including desensitization with at least 25 different clients?*
Have you received a minimum of 20 hours of Attachment-Focused EMDR consultation for certification by a Parnell Institute Consultant?*
All consultation hours for Certification in Attachment-Focused EMDR must be received from a Parnell Institute Approved Consultant or Consultant-in-Training. At least 10 of these Consultation hours must be individual hours with the same Parnell Institute consultant. The remaining 10 hours may be obtained through small group consultation. *Only consultation hours received AFTER completion of the Basic Training program can be applied towards this requirement.
Who was your consultant?*
Attach letter(s) of recommendation from your Approved Consultant(S) regarding your utilization of Attachment-Focused EMDR. Recommendation letter(s) must include verification of number of hours you received, dates of commencement and completion, and how many of those hours were individual consultation and how many were group consultation.
Max. file size: 256 MB.
Have you completed the 12-hour "Attachment-Focused Healing Relational Trauma and Adults Abused as Children Workshop" and completed an assessment?*
Have you read the required reading: A Therapist’s Guide to EMDR, Attachment- Focused EMDR: Healing Relational Trauma; Tapping In; Rewiring the Addicted Brain With EMDR-Based Treatment; The Body Keeps the Score?*
Have you satisfied the requirement for video and live session evaluation and feedback?*
Agreement Policy*
I agree to the statements below.
I have read and agreed to the Parnell Institute policies for recertification every two years.

I have read and agreed to adhere to all Parnell Institute policies and to observe the ethical and professional code of conduct of my respective clinical profession.
Signature*

Forms

Application for Certification in AF-EMDR

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