Forms

Licensure and Training Verification – Part 3

Name*
First Last
Email*
Please list which training dates you are registering for:*
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.
Please list the name of your PI consultant.
Have you completed your 10 consultation hours? If not, when do you expect to complete them?*
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: 256 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.

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.
Upload Your Parts 1 & 2 Certificate*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Please upload these items:
2. Upload a copy of your Parts 1 & 2 certificate.

*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.
Upload Your Confirmation of 10 Consulting Hours
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Please upload these items:
3. Upload a copy of verification of your completed 10 hours with a consultant.

*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.
Will you require CEs?
- Yes
- No