Registration Type *

Please indicate which type of registration

New Member (1st year Free until Dec 31)

Renewal with changes ($20 fee)

Renewal without changes ($20 fee)

Adding to Consultant Page (additional $10)

Making changes (current year dues already paid)

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. 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.

Paypal

Already Paid

1st Year Member - no payment required

Mail a Check (email: wnysteeringcommittee@gmail.com for address)

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 - (Commercial)

BCBS - (Commercial)

Univera - (Commercial)

Empire

Atnea - (Commercial)

CIGNA (Commercial)

Medicaid/CHP

Medicare

Hours

Please indicate your availability

Weekdays

Evenings

Weekends

Office Setting *

Please indicate the setting in which you provide therapy

Clinic

Group Practice

Private Practice

Practice Setting *

Please indicate how you see clients.

In Person

Telehealth

Both

Code of Conduct *

Checking the box below indicates your agreement to abide by the Code of Conduct.

I have read, understand, and agree to the Code of Conduct