San Diego Regional EMDR Basic Training Clinical Supervisor Agreement 2024
Alicia Avila Licensed Clinical Social Worker P.C.
Lic. LCS19899 3990
4629 Cass St. #368, San Diego, CA 92109
(858) 344-9440
alicia@aliciaavila.com

The Basic EMDR Therapy Training Program is open to licensed practitioners and to those who are on a licensure track if they are at the end of completing Ph.D. or master’s level coursework in the final internship, and are being supervised by a licensed clinician in a clinical internship.

The following information is important for the Supervisor to know:

1. The EMDR training is designed for clinicians to begin to implement portions of EMDR, as clinically appropriate in their practice throughout the course.  Training and consultation dates are spread out to assist with questions as they come up from the experience of direct clinical practice.

2. The boundaries of clinical applications of EMDR therapy for anything other than PTSD have not yet been confirmed by controlled research. The cautions presented in the training are based primarily on anecdotal reports by trained clinicians. The most recent research on EMDR therapy can be found at www.EMDRIA.org.

3. It is not unusual for a target memory to be linked to other unexpected, potentially disturbing material or memories.

4. A prerequisite for receiving a Certificate of Attendance is the completion of the six practice sessions at the seminar, where clinicians will give and receive EMDR therapy under small group supervision. The practice experience is for educational purposes using the participant’s personal material.  While the experience can be therapeutic it is and not personal therapy.

5.Case material presented didactically or on video may be disturbing to those with unresolved personal issues.
• Clinicians presently engaged in personal therapy must seek permission from their therapist before participating in the training; and
• Those who presently have a dissociative disorder should not participate without informing the EMDR trainer at the training; and
• Those with limiting or special medical conditions (such as but not limited to pregnancy, heart condition, seizures, ocular difficulties, etc.) must consult their medical professionals prior to participating in this training.

6. Since the processing of targeted incidents may continue after training, other dreams, memories, etc. may surface. In such cases, it is the responsibility of the participant to seek and obtain appropriate assistance. Providing such assistance is neither a part of nor an extension of the training. Clinicians who wish to continue with personal EMDR therapy work can request referral information from the Trainer.

7. This EMDR Basic Training course prepares the clinician for providing EMDR therapy for clinical or research purposes only and does not qualify the participant to train others in EMDR therapy.  This basic training course does not prepare a clinician to work with special populations or dissociation if this is not already part of their training or experience.  

8. A Certificate of Completion will be issued only to those who complete the full course including all lectures, fully participate in all practice sessions and complete the ten hours of consultation.  This is the initial step in EMDR and does not constitute certification in EMDR therapy.  Certification is an advanced standing in EMDR.  Certification information can be found on: https://www.emdria.org/emdr-training/emdr-certification-2/

By completing the information below with your professional contact information and providing your signature, you confirm that you have read the description of EMDR and the method of training, and you affirm the decision of your supervisee to participate in the training described and to use the clinical knowledge acquired in the training, as appropriate, in the clinical work that you supervise, and you confirm that you supervise the supervisee at the organization listed on the Participant Agreement Form.
Sign in to Google to save your progress. Learn more
Email *
Agreement *
Required
Print Supervisee's Name
Print Supervisor Name *
Date *
MM
/
DD
/
YYYY
Title *
Name of Organization *
Phone Number *
Address *
Your Academic Degrees
Your License Number(s), including State
Any additional information you would like to share with the Training provider about the supervisee?
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of aliciaavila.com. Report Abuse