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Account Information

Please complete the form below to register as an online Rosenzweig Center for Rapid Recovery student.

Title

First*

Middle

Last*

Suffix

Street address*

City*

Country*

State/Province*

Postal code*

This address is a* Business Address Home Address

Work phone

Extension

Home phone

Fax

Cell*

Email*

Secondary email

Password*

Confirm password

Place of employment*

Have you ever been trained in or used an eye movement therapy?* Yes No

Emergency contact name

Emergency contact phone

Licenses

If your jurisdiction or license type is not available below, please contact our office to provide your license information. If you do not have a license, click here to view the minimum requirements to take an ART Basic Training.

Jurisdiction*

Type*

Number*

Expiration

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Account Information

Licenses Add

Licenses