• EMDR Recommendation Request

  • PLEASE READ BEFORE BEGINNING • Submit this form one time only. • Have consultation dates and hours available before beginning. • Certification applicants should have their EMDR basic training certificate available for upload. • Do not include client names, initials, dates of birth, or other identifying client information anywhere in this form. • Standard processing may take 30+ days, and duplicate submissions or additional emails do not expedite processing. • If you discover an error after submitting, do not submit the form again; contact Sam with the correction. • For expedited processing information, visit: https://www.mantramentalhealthllc.com/documentation-and-recommendations#expediting-your-documentation

  • PART 1: ABOUT YOU + YOUR REQUEST

  • What credential are you requesting a recommendation for?*
  • Format: (000) 000-0000.

  • PART 2: CONSULTATION + TRAINING INFORMATION

  • 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*

  • EMDR consultation hours completed with Sam

    List ALL consultation hours completed with Sam that apply to the credential you are pursuing and should be included in this ONE consolidated document. For each consultation, include the date, duration, and format (individual or group). Example: 1/1/26, 2 hrs, group; 1/4/26, 1 hr, individual. Do not submit separate forms for separate consultation dates. For certification applicants, do not include consultation completed as part of your EMDR basic training. For Approved Consultant applicants, include only consultation applicable toward Approved Consultant status.

  • Other consultants

    Provide names of all other consultants you've done certification hours with and identify how many hours were individual and how many were group.

  • PART 3: EMDR CLINICAL SELF-ASSESSMENT

  • Please rate your current knowledge, confidence, and/or competence in each area based on how you actually practice at this time. This is not about selecting the answer you believe you “should” give. Your responses help me understand your perception of your current strengths and areas for continued development.

  • Adapting EMDR

    Provide an example of adapting EMDR to a population, presentation, or individual client while maintaining fidelity, including the clinical reasoning for the adaptation. Do not include identifying client information.

  • Working with and adapting to different populations*

  • Consultee self-reported skills

    Please complete the below questions surrounding your EMDR skills/knowledge
  • Gathering client history*
  • Resourcing*
  • Assessing client appropriateness for EMDR therapy*
  • Assessing client preparedness for reprocessing*
  • Assessing/screening for dissociation*
  • Explaining the EMDR therapy process to clients*
  • Preparing clients for EMDR therapy*
  • Clinician's understanding of the mechanics of EMDR (e.g. seating, distance, stop signal, etc)*
  • Staying "out of the way" while reprocessing with clients*

  • Reprocessing challenges

    Describe THREE instances in which reprocessing became stuck, looping, disrupted, or otherwise required you to consider changing your approach. For each example, briefly address what you noticed, how you understood what was happening, what you did or changed, and what informed your decision. Do not include identifying client information.

  • Dealing with the ‘looping’ and ‘stuck processing’? (e.g. change direction, speed or amount of eye movements; change modalities; cognitive interweave)*
  • Closure at the end of a session with an incomplete target*

  • Eight phases of EMDR

    Briefly describe each of the eight phases of EMDR therapy, including the primary purpose or clinical task of each phase.

  • Treatment/target planning for EMDR*
  • Applying the standard EMDR 8 phase protocol*
  • Discussion/presentation of cases in consultation*

  • PART 5: CONSULTATION PRACTICE + APPROVED CONSULTANT READINESS

  • ONLY COMPLETE THIS SECTION IF YOU ARE WORKING TOWARD EMDRIA APPROVED CONSULTANT STATUS. If you are completing this form for EMDR Certification only, skip this section. If you are requesting a recommendation for EMDRIA Approved Consultant status, you must complete all questions in this section.
  • Approved Consultant applicants — presenting EMDR concepts in ways consultees can understand.
  • Approved Consultant applicants — providing constructive feedback.
  • Approved Consultant applicants — managing consultation group dynamics effectively.
  • Approved Consultant applicants — understanding responsibilities, limitations, and boundaries of the EMDR consultant role.

  • PART 6: YOUR DEVELOPMENT DURING CONSULTATION

  • Development during consultation

    How has your EMDR practice developed during the time we have worked together in consultation? You may include changes in your clinical understanding, confidence, case conceptualization, use of the eight-phase protocol, decision-making, adaptations, or areas where you have continued to grow.

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  • PART 7: POLICIES + REQUIREMENTS

  • Please review Sam’s current professional consultation policies, consent to services, and guidelines before submitting this request.

  • PART 8: RECOMMENDATION READINESS + ATTESTATION

  • A Recommendation Is Not Guaranteed Submitting this form or completing the required consultation hours does not guarantee that I will provide a recommendation for EMDR Certification or Approved Consultant status. A recommendation reflects my professional assessment that I have sufficient information to support your readiness for the credential you are pursuing. If I do not yet have sufficient information to make that determination, or if I identify areas that need further development, I may require additional information, supporting materials, consultation, training, or other steps before providing a recommendation. When appropriate, I will identify areas requiring further development and discuss potential next steps with you.
  • Please acknowledge the following:*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: