Nonprofit Eligibility & Discount Form

The nonprofit agency discount is intended for clinicians employed full-time in small, community nonprofit agencies. The discount is not available for unionized employees of large staff model HMOs such as Kaiser Permanente; city, county or state government agencies; or federally qualified health centers.

Nonprofit Eligibility & Discount Form

To request an agency discount, please submit this form with your registration application and upload a letter on agency stationery from your employer confirming full-time employment.
Participant’s Name*
Participant’s Job Title*
Name of Agency*
Clinical Supervisor’s Name*
Clinical Supervisor’s Title*
Clinical Supervisor’s Phone Number*
Management Supervisor’s Name (if applicable)
Management Supervisor’s Title (if applicable)
Agency Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Briefly describe the population the agency serves*
Describe your job*
How many psychotherapy clients do you see and with what frequency?*
Do other clinicians in your agency currently use EMDR Therapy with clients? If yes, please describe*
Are your first and second line supervisors familiar EMDR Therapy?*
Are they supportive of your intention to use EMDR Therapy with agency clients?*
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