Registration Type *

Please indicate which type of registration

New Member (1st year Free until Dec 31)

Renewal, information already on website

Renewal, need to add to website

Already a member, and paid, just making changes to profile

Membership Application Preferences *

Please indicate below if you want your information added to the website

Yes

No

Payment *

Membership fees are 20 dollars per year, your information will only be added after payment received. Please indicate how you wish to pay. After filling out form you will be directed to pay via PayPal, if you have already submitted payment via mail please disregard. First year is free to new members. Membership fees are due Jan 1st of each year.

Credit Card - https://www.westernnyemdr.com/membership/annual-membership-1

Paypal

Already Paid

1st Year Member - no payment required

Name *

First Name

Last Name

Licensure

LMHC-P

LMHC

LMSW-P

LMSW

LCSW

LCSW-R

PhD

PMHNP

Other

EMDR Training Level

Please indicate what level of training and certification you hold, we will verify on emdria.org your certification level.

EMDRIA Basic training (levels 1 & 2) - Trained by

EMDRIA Certified

EMDRIA Approved Consultant In Training (CIT)

EMDRIA Approved Consultant

EMDRIA Approved Trainer

Treatment Populations

Please indicate what populations you serve

Adults

Children (up to 11)

Children (11 to 17)

Elderly

Families

Couples

LGBTQ

Do you specialize in the treatment of law enforcement, first responders or hospital staff?

You can also mark yes if you are interested in treating this population.

Yes

No

HAP/TRN

If you specialize or are interested in the treatment of law enforcement, first responders or hospital staff, would you like to hear about how you can be a part of the Humanitarian Assistance Program?

Yes

No

Insurances Accepted

Please check what insurances you accept, please indicate in the text box below if there are any more you accept that are not listed.

IHA

BCBS

Univera

Molina (formally YourCare)

Beacon

CIGNA

Child Health Plus

Fidelis

Hours

Please indicate your availability

Weekdays

Evenings

Weekends

Office Setting *

Please indicate the setting in which you provide therapy

Office, in person

Telehealth

Practice Setting *

Please indicate how you see clients.

In Person

Telehealth

Both