Please initial each box after you have read the material. 
 
EMDR is a simple but efficient therapy using bilateral stimulation (BLS) ─ tapping, auditory tones or eye movements ─ to accelerate the brain's capacity to process and heal a troubling memory. BLS, which occurs naturally during dream sleep, causes the two brain parts to work together to reintegrate the memory. Some clients experience relief or positive effects in just a few sessions. EMDR is effective in alleviating trauma-related symptoms, whether the traumatic event occurred many years ago or yesterday. It gives desired results –with little talking, without using drugs, and requires no “homework” between sessions.   INITIAL   
 
Scientific research has established EMDR as effective for the treatment of post traumatic stress, phobias, panic attacks, anxiety disorders, stress, sexual and physical abuse, disturbing memories, complicated grief and addictions.   INITIAL   
 
The possible benefits of EMDR treatment include the following:

• The memory is remembered but the painful emotions and physical sensations and the disturbing images and thoughts are no longer present.
• EMDR helps the brain reintegrate the memory and store it in a more appropriate place in the brain. The client’s own brain reintegrates the memory and does the healing.   INITIAL   

 
The possible risks of EMDR treatment include the following:  

• Reprocessing a memory may bring up associated memories. This normal and those memories will also be reprocessed.
• During the EMDR, the client may experience physical sensations and retrieve images, emotions and sounds associated with the memory. Reprocessing of the memory normally continues after the end of the formal therapy session. 
• Other memories, flashbacks, feelings and sensations may occur. The client may have dreams associated with the memory. Frequently the brain is able to process these additional memories without help, but arrangements for assistance will be made in a timely manner if the client is unable to cope. INITIAL   

 
As with any other therapeutic approach, reprocessing traumatic memories can be uncomfortable; that means, some people won’t like or be able to tolerate EMDR treatment well. Others need more preparation, offered by the therapist, before processing traumatic

• events using EMDR. There are no known adverse effects of interrupting EMDR therapy; therefore, a client can discontinue treatment at any time. 
• Alternative therapeutic approaches may include individual or group therapy, medication, or a different psychotherapy modality. 
• EMDR treatment is facilitated by a licensed psychotherapist having EMDRIA-approved training.    INITIAL   

 
HISTORY AND SAFETY FACTORS 
The client must:

• Be willing to tell the therapist the truth about what he/she is experiencing.   INITIAL   
• Be able to tolerate high levels of emotional disturbance, have the ability to reprocess associated memories resulting from EMDR therapy, and to use self control and relaxation techniques (eg. calm place exercise).   INITIAL    
• Remember debriefing instructions and call his/her therapist, connect with supportive family or friends, or use meditation or other techniques (eg. calm place exercise) he/she has agreed to in therapy, if needed.   INITIAL   
• Disclose to therapist and consult with his/her physician before EMDR therapy if he/she has a history of or current eye problems, a diagnosed heart disease, elevated blood pressure, or is at risk for or has a history of stroke, heart attack, seizure, or other limiting medical conditions that may put him/her at medical risk. Due to stress related to reprocessing traumatic events, pregnant women should consider postponing EMDR therapy.   INITIAL
• Inform therapist if he/she is wearing contact lenses and will remove them if they impede eye movements due to irritation or eye dryness. The therapist will discontinue bilateral stimulation (BLS) eye movements if client reports eye pain and use other dual stimulation (tapping, sounds)to continue reprocessing.   INITIAL
• Assess his/her current life situation to determine EMDR approach. Client may need the ability to postpone demanding work schedule immediately following EMDR session.   INITIAL
• Before participating in EMDR, discuss with therapist all aspects of an upcoming legal court case where testimony is required. The client may need to postpone EMDR treatment if she/he is a victim or witness to a crime that is being prosecuted because the traumatic material processed using EMDR may fade, blur or disappear and her/his testimony may be challenged.   INITIAL  
• Understand disagreements with family and/or friends may occur as she/he learns new skills such as assertiveness or social skills after processing problems and disturbing material using EMDR. Vulnerable clients may need to be protected.  INITIAL 
• Be willing to explore the issues(s) that may arise as change occurs. For example, changes regarding your identity; finances; loss of identification with a peer group; and/or attention.   INITIAL 
• Consult with his/her medical doctor, before utilizing medication. Some medications may reduce the effectiveness of EMDR. For example, benzodiazapines may reduce effectiveness possibly due to state-dependent processing and/or regression may occur after ceasing anti-depressants.   
• Address with the therapist his/her ability to attend to EMDR due to recent cocaine dependence, long term amphetamine abuse, seizures, and/or other neurological conditions. EMDR is contraindicated with recent crack cocaine users and long-term amphetamine users.   INITIAL   
• Discuss with the therapist any Dissociative Disorders; Dissociative Identity Disorder unexplained somatic symptoms, sleep problems, flashbacks, derealization and/or depersonalization, hears voices, unexplained feelings, memory lapses, multiple psychiatric hospitalizations, multiple diagnoses with little treatment progress - EMDR may trigger these symptoms.    INITIAL   

 
I HAVE READ AND I UNDERSTAND THE POSSIBLE OUTCOMES OF EMDR LISTED ABOVE AND UNDERSTAND I CAN END EMDR THERAPY AT ANY TIME. I AGREE TO PARTICIPATE IN EMDR TREATMENT AND I ASSUME ANY RISKS INVOLVE IN SUCH PARTICIPATION: