EMDR Consultation Questionnaire and Agreement
Name
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First Name
Last Name
Credentials (e.g.: LCSW, LPC, PsyD, REAT, etc.)
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Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please provide ANY/ALL addresses that you may be at during consultation. This is for safety purposes, you won't be getting mail from me unless discussed.
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Review my consultation policies, consent to services, and guidelines and agree to the terms. Read them here: https://www.mantramentalhealthllc.com/professional-consultation. Please email me if you feel it'd be helpful to review these policies one-on-one/verbally.
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I fully read the content of the above website and agree to and understand it's terms.
Please attest to your agreement and understanding of the requirements set forth in my polices regarding using Sam as your primary consultant for the certification or consultant process. Policies: https://www.mantramentalhealthllc.com/professional-consultation
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I have read and understand the requirements and expectations for having Sam as my primary consultant for certification
I have read and understand the requirements and expectations for having Sam as my primary consultant for the consultant status process
This is not applicable (I have another primary consultant or I'm not seeking certification or consultant status at this time).
Using Sam as your primary consultant for your EMDR Certification: Sam requires that you complete at least 10 individual, certification-level consultation hours with her for her to act as your primary consultant + provide a recommendation for your EMDR Certification
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I understand/agree
What is your current work setting? (Agency/non-profit, private practice, etc. Please include all if you have multiple work settings)
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How many clients do you typically see weekly?
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What is your clinical background? (Other training, types of therapy you do, etc.)
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Who is the trainer (The name of the lead trainer) and approximate dates (month/year) of your pt 1 EMDR basic training?
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Who is the trainer (The name of the lead trainer) and approximate dates (month/year) of your pt 2 EMDR basic training? (If you have completed or scheduled it)
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The purpose of this agreement is to establish a clear understanding of the expectations of consultation. There are several different reasons a consultee seeks consultation. Which reason is of primary importance to you now?
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To complete the 10 hours of consultation to meet EMDR basic training requirements
To gain knowledge regarding complex trauma, build confidence using EMDR, but not EMDRIA credential purposes
To achieve the EMDRIA Certification credential
To achieve the EMDRIA Approved Consultant credential
Expressive Arts Supervision
Other
Please list any other reasons for seeking consultation aside from the primary reason you chose above
*IF you were not trained through ICM/ an ICM affiliate* (not required for those trained within ICM/ by an ICM trainer): If you're working on certification or CIT hours, please upload an image of your certificate of completion for your basic training/foundational training- a screenshot or photo is fine.
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Consultee self-reported skills
Please complete the below questions surrounding your EMDR skills/knowledge
Gathering client history
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1 (not confident at all)
2
3
4
5 (very confident)
Working with and adapting to different populations
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1 (not confident at all)
2
3
4
5 (very confident)
Resourcing
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1 (not confident at all)
2
3
4
5 (very confident)
Assessing client appropriateness for EMDR therapy
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1 (not confident at all)
2
3
4
5 (very confident)
Assessing client preparedness for reprocessing
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1 (not confident at all)
2
3
4
5 (very confident)
Assessing/screening for dissociation
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1 (not confident at all)
2
3
4
5 (very confident)
Explaining the EMDR therapy process to clients
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1 (not confident at all)
2
3
4
5 (very confident)
Preparing clients for EMDR therapy
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1 (not confident at all)
2
3
4
5 (very confident)
Understanding of the mechanics of EMDR (e.g. seating, distance, stop signal, etc)
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1 (not confident at all)
2
3
4
5 (very confident)
Staying "out of the way" while reprocessing with clients
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1 (not confident at all)
2
3
4
5 (very confident)
Dealing with the ‘looping’ and ‘stuck processing’? (e.g. change direction, speed or amount of eye movements; change modalities; cognitive interweave)
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1 (not confident at all)
2
3
4
5 (very confident)
Closure at the end of a session with an incomplete target
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1 (not confident at all)
2
3
4
5 (very confident)
Treatment/target planning for EMDR
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1 (not confident at all)
2
3
4
5 (very confident)
Applying the standard EMDR 8 phase protocol
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1 (not confident at all)
2
3
4
5 (very confident)
Using modifications for special populations or issues (addiction, phobias, etc.)
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1 (not confident at all)
2
3
4
5 (very confident)
Discussion/presentation of cases in consultation
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1 (not confident at all)
2
3
4
5 (very confident)
What are your goals for consultation?
Please share anything else you feel would be helpful for our consultation:
Please sign below attesting to your understanding and agreement of the consultation and services agreement as well as attesting that all information provided here is accurate and complete.
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