Registration Agreement for ___________TraumaTherapy.com

A MyTraumaTherapy.com Web Directory of Certified EMDR Therapists

(or those who have completed at least 5 of their 20 hours of Consultation toward EMDRIA Certification)

Name ________________________________________ Title _______________________________________

Business Address ___________________________________________________________________________

City ______________________________________  Zip  _______________________  State ______________

Business Phone  ________________________________  Cell  _______________________________________

Fax __________________________________________

Mail the following to MyTraumaTherapy, 3537 Boundary Street, San Diego, CA  92104:

  • Registration Fee of $150 
  • Copy of my EMDRIA-Certification in EMDR, Approved Consultant, Facilitator, or Trainer Certification
  • OR, a letter from my EMDRIA-Approved consultant stating I’ve completed at least 5 hours of consultation and giving the expected date of completion of my certification
  • My professional license copy
  • My liability insurance copy

I, _____________________________________________, understand the following:

  • my registration fee is non-refundable
  • when I receive email confirmation of approval, I will be given instructions to log in to the site and complete my profile online. Video tutorials will help me me with this process, and I can also make an appointment with Dana or Karen to be walked through the process by phone.
  • when I log-in to activate my profile page, I must click on the “Subscription” button which takes me to PayPal to completed the enrollment for the monthly subscription fee of $29.00  This will be charged beginning one month from the date I log in (giving me one free month).
  • I am free to make changes or edits after that at any time I need.  I understand I can submit short articles to MyTraumaTherapy to promote my specialties and link to my Profile Page.
  • If I have any questions or need assistance, I can contact Dana Terrell or Karen Walker at 619 283-5665, or by email at danaterrell.lcsw@gmail.com

My signature below signifies that I agree to all of the above terms.

Signature______________________________________________                Date _____________________

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