Join EMDRAA - Full Membership application form for EMDRAA Full Membership Name* Mr.Mrs.MissMs.Mux.Dr.Prof.Rev. Prefix First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For account identification purposesProfession & Registration*Select an optionCounsellorClinical NeuropsychologistClinical PsychologistFamily TherapistForensic PsychologistMedical DoctorMental Heath NurseOccupational TherapistProvisional PsychologistPsychiatric NursePsychiatristPsychologistPsychotherapistSocial WorkerOtherIf the selection you are looking for is not displayed, please contact EMDR Association of Australia Ltd by emailing email@example.com with your enquiry.Other Profession* List your profession not noted in the list above and you will be contacted to clarify.Type of Counsellor*Select an optionCounsellor-Psychotherapist PACFACounsellor PACAWACounsellor NZCounsellor ACAOther CounsellorType of Social Worker*Select an optionMental Health / Clinical Social WorkerSocial Worker - OtherHighest Qualification* Year Awarded Highest Qualification* Institution Awarding Highest Qualification* Year Completed Initial / Part One EMDR Training?* Initial Training (Part One) Provider's Name* Year Completed Final / Part Two EMDR Training?* Final Training (Part Two) Provider's Name* Name/s of EMDRAA approved Consultant/s who can verify that you have completed 10 hours of consultation*Email/s of EMDRAA approved Consultant/s who can verify that you have completed 10 hours of consultation, separated by commas or on separate lines*Do you carry Professional Indemnity Insurance?*Select an optionYesNoCovered by EmployerNot ApplicableAre you from New Zealand? Yes New Zealand based therapists must meet the following criteria: Training is restricted to mental health professionals (with clinical experience) who have a minimum of a four year tertiary qualification (post graduate level or equivalent) in the mental health sector. A minimum of NZQA level 8 is required. Acceptable Qualifications include: Fully registered health professionals with specialist training in mental health (Psychiatry, Clinical Psychologists, Psychotherapists, Nurses, Mental Health Social workers). Training needs to include training in specific psychological interventions, like CBT, DBT etc. Mental health professionals not covered by NZ legislation e.g. Counsellors who have a minimum of 4 years academic study, including a Master’s degree or have completed post-graduate qualifications (Honours, Post Graduate Diploma or higher) in mental health; have undertaken training in specific psychological interventions and have worked two years full time (or part time equivalent) under supervision in a mental health setting. All Clinicians must have FULL registration with their professional association. Provisional is insufficient. By proceeding with this Application for Full Membership I declare I consent to becoming a member of EMDRAA Ltd which is a company limited by guarantee. By proceeding with this Application for Full Membership I am declaring I am fully trained to EMDRAA standards, i.e. I have completed an Accredited Part One and Part Two training AND had 10 hours of Case Consultation with an EMDRAA Approved Consultant. As a Full Member I understand I have voting rights, can stand for election to the Board, can list my details on the EMDRAA Find a Therapist service, and I have other rights and responsibilities as outlined in the Constitution. Declaration* I agree to the declaration as outlined above.