REGISTRATION FORM

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REGISTRATION FORM

EMDR Basic Training with Gina Ornelas - WINTER, 2026- Fresno/Madera, CA

I am registering for . . . . *

Part 1 January 23-25, 2026

Part 2 March 13-15, 2026

BOTH Parts 1 and 2

Name *

Email *

Phone Number *

Licensure *

Fully Licensed Clinician

Unlicensed Clinician (working toward licensure)

Student

Company name

License Type and Number (or n/a) *

For associates, interns or students

I have at least six months of clinical experience under the supervision of a state-licensed Mental Health clinician.

My supervisor will email ginaornelas@gmail.com stating eligibility/preparedness and supervisor’s acknowledgement that EMDR facilitators/consultants do not provide supervision at least two weeks before the training.

Reviewing

Check this box if you have previously completed an EMDRIA approved EMDR training and are reviewing.

For APA reporting

I am a licensed psychologist seeking CE Credits.

Eligibility *

I understand that in order to complete this course I must participate in two practicum sessions (per weekend) in which participants will conduct EMDR with each other (with traumatic memories from their own lived experience) under the close observation of a skilled EMDR consultant/facilitator. This means that I am sufficiently psychologically stable to assume both the role as a therapist and a client. (Please note: if you are currently a client in psychotherapy, it is your responsibility to consult with your therapist to determine whether you are psychologically fit to participate in this training.)

Required

Fees *

I understand that fees are fully refundable minus the payment processing fee up until two weeks before the beginning of the training; after that no refunds or credits will be given except under extraordinary circumstances.

Required

Fees *

I understand my registration is incomplete until payment is received.

Required

Grievances *

Any grievance should be directed to the trainer or any facilitator present at the training. There will be a minimum of one facilitator for every 9 participants. A copy of the grievance procedures will be made available to any participant who requests it.

Required

Training Completion *

I understand that to complete EMDR Basic Training I must attend Part 1, Part 2, and 10 hours of consultation within a 12 month period.

Required

Is there anything else you would like Gina to know about you? Do you need accommodations?

How did you hear of this training?

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