IEDTA Therapist Directory Application Form To be listed in the Therapist Directory, you must be an IEDTA member. If you are an IEDTA member, please add your listing here. If are not an IEDTA member and you want to be listed, please join the IEDTA. Your NameFull name*Include any Suffixes (such as MSW or MD) i.e. "Astra Perspera, MSW" Given name only (First Name, e.g. "Astra"):*Surname only (Last Name, Family Name, e.g. "Peraspera"):*This name determines where your entry appears alphabetically. In the US, this name usually appears last. Do not add prefixes or suffixes (e.g. "PsyD") to this field.About Your Therapeutic PracticeIntroductory Sentences (Special Interests or Comments)Licensing Authority (e.g. "Board of Registration in Medicine, Massachusetts, USA"):License or Certificate Number:In Practice Since (Year):Therapy offered (e.g. Individiuals, Families, Couples, Groups):Age Groups Treated (e.g. "18-65"):Languages spoken:Describe any training or supervision you offer:About Your Education & ExperienceProfessional Degree (e.g. MA, PhD, MD, etc.):Professional Degree Earned (Year):Post-Degree Professional Training:IEDTA Certification (e.g. "teacher/supervisor, or graduate of IEDTA certified core training):Practicing EDT Since (Year):Number of Years of EDT Training:Location & Contact InformationEnter information for your primary location. Enter any secondary locations in the notes field.Street Address:Town or CityState, Province or RegionPostal or Zip CodeCountry (e.g. "USA," "Lebanon," etc.):Telephone (including country code, e.g. "+1" for US and Canada, "+44" for UK):Fax:Email: Notes & Other Location Information (e.g. a second address; leave blank if none):Web Site URL (e.g. "http://www.peraspera.net") Press "Submit" to complete this form.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.