Forms

Licensure and Training Verification – Part 3

Name*
First Last
Email*
Emergency Name & Contact Phone Number*
Please list the location and date for the event you are attending.*
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.
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.

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

3. The sign consent form you received in the confirmation email you received after purchase. (Be sure to check your spam folder and promotions folder for this email.)

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.
Will you require CEs?
- Yes
- No

Forms

Licensure and Training Verification – Part 3

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