Oregon EMDR : Therapist Application
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Email *
Today's Date *
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Name *
First and last name
Website Address
Phone number *
Home Address- Street, city, state and zip *
Submit your cover letter or resume:  Link or copy and paste
Are you a Citizen of the United States? *
Have you ever worked for this company? *
Are you authorized to work in the United States? *
Are you a licensed mental health clinician in the State of Oregon? *
Are you a Registered Intern in the State of Oregon? *
Licensing Board *
License or Registration Number *
Have you ever had a complaint against your license in any jurisdiction? *
Is there any current disciplinary action pending against your license? *
Name of High School, Location, Dates of Attendance *
Did you graduate? *
Degree Received *
Name of Undergraduate Institution, Location, Dates of Attendance *
Did you Graduate? *
Degree Received *
Name of Graduate Institution, Location, Dates of Attendance *
Did you Graduate? *
Degree Received *
Name of Other Institution, Location, Dates of Attendance
Did you graduate?
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Degree Received
Have you ever provided Telehealth Therapy? *
On a scale of 1-5, how comfortable are you with technology?   *
Not at all comfortable
Extremely comfortable
Current Employer, Position, Dates of Employment, Name of Direct Supervisor *
Past Employers, Positions, Dates of Employment, Names of Direct Supervisors (Please list 5 years of employment or volunteer experience, as well as, internship experience.) *
Have you completed an EMDRIA-Approved EMDR Basic Training? *
If 'yes', please provide the name of the training provider and date of completion.
Have you completed any level of training in Sensorimotor Psychotherapy, Somatic Experiencing or IFS? *
If 'yes', please indicate the highest level of training completed and date of completion. *
List all other advanced clinical training you've completed and dates of completion.
Please write a brief narrative response to the following questions:  Your client presents with a flat affect, poor eye contact and tells you they feel hopeless and have been thinking about suicide.  Please describe 2 possible responses. *
Your new client makes several comments about items in your office, asks if you have children and if you like dancing.  Please describe 2 possible ways you might respond. *
Your supervisor requests that you complete an administrative task by the end of the week.  Please describe steps you would take if you didn't think you could complete the task by the end of the week. *
Please attest to the following statement:  I understand that Therapy Dogs and Services Dogs are often present at the Oregon EMDR workplace and I attest that I am comfortable in their presence. *
Required
Please attest to the following statement:  I understand that Oregon EMDR, LLC welcomes and celebrates people from diverse ethnic, religious, gender, sexual-affectional and familial orientations and identities.   I attest that should I be offered employment, I will not pathologize or otherwise discriminate against any persons I encounter in my work with Oregon EMDR, LLC. *
Required
Please provide three professional references with email addresses below. *
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