Certification recommendation and documentation of hours letter request and certification readiness questionnaire and agreement.
--This form is for consultees who have been working closely with Sam on the certification process and have already explicitly established that Sam is your primary consultant for the EMDR certification process. This form is required before Sam will be able to write a recommendation letter for your certification application. Sam aims to complete recommendation letters within 30 days of you submitting this form but it may take longer depending on holidays, out of office dates, etc. --Completing the required consultation hours for certification and consultant status doesn’t automatically guarantee that you will be prepared for certification or approved consultant status when you complete these hours. In some situations, I may require consultees to complete additional consultation hours with me or a different consultant or additional training prior to completing a recommendation for certification or consultant status for you and I reserve the right to do so.
Name
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First Name
Last Name
Pronouns:
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Credentials (e.g.: LCSW, LPC, PsyD, REAT, etc.)
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Review my consultation policies, consent to services, and guidelines and agree to the terms. Access 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 certification or for becoming a consultant. 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).
I have reviewed and understand EMDRIA's certification criteria and requirements https://www.emdria.org/emdr-training/emdr-certification-2
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I agree
EMDR Consultation hours with Sam Bergstein: Dates, duration, and format (individual or group format) of each consultation. Use the structure of these examples: 1/1/25, 2hrs, group format; 1/4/25, 1hr, individual format. **Only include those hours earned towards certification (basic training consultation hours do not count towards certification)***
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Provide names of all other consultants you've done certification hours with AND identify how many hours were individual and how many were group.
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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)
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5 (very confident)
Describe your process of history gathering
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Working with and adapting to different populations
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1 (not confident at all)
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5 (very confident)
Provide an example (without identifying client info) of how you have adapted to different population.
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Resourcing
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1 (not confident at all)
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5 (very confident)
Describe your resourcing process
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Assessing client appropriateness for EMDR therapy
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1 (not confident at all)
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5 (very confident)
Describe your processes of assessing client appropriateness for EMDR
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Assessing client preparedness for reprocessing
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1 (not confident at all)
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5 (very confident)
Describe your process of assessing client preparedness for reprocessing
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Assessing/screening for dissociation
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1 (not confident at all)
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5 (very confident)
Describe your process of assessing for dissociation
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Explaining the EMDR therapy process to clients
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5 (very confident)
How do you go about explaining the EMDR therapy process to clients?
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Preparing clients for EMDR therapy
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1 (not confident at all)
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5 (very confident)
Describe your process of preparing clients for EMDR
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Clinician's understanding of the mechanics of EMDR (e.g. seating, distance, stop signal, etc)
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1 (not confident at all)
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5 (very confident)
Describe how the mechanics of EMDR show up in your practice (without identifying client info)
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Staying "out of the way" while reprocessing with clients
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1 (not confident at all)
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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)
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5 (very confident)
Describe 3 instances of a client "looping" or "being stuck" and how you dealt with the situation (without identifying client information)
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Closure at the end of a session with an incomplete target
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1 (not confident at all)
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5 (very confident)
Describe your process of closing a session with an incomplete target
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Treatment/target planning for EMDR
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1 (not confident at all)
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5 (very confident)
Describe your treatment/target planning process for EMDR
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Applying the standard EMDR 8 phase protocol
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1 (not confident at all)
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5 (very confident)
Give a brief description of each of the 8 phases
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Discussion/presentation of cases in consultation
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1 (not confident at all)
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5 (very confident)
Please provide info on how your EMDR practice has evolved since your basic training:
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Upload an image or document of your EMDR basic training certificate of completion
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