Oregon EMDR Case Consultation Worksheet

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Feel free to use this form as a guide to help you organize your thoughts. It is not required that all fields are completed prior to our consultation. When completing the form, a ‘less is more’ approach is best. If there’s too many words, the important information will get lost. Feel free to enter "n/a" in any field. PLEASE NOTE: This form is housed in a drive that is NOT HIPAA secure so be sure to eliminate any identifying information.

Email *

Your first name *

Today's Date *

YYYY

General Description of client: *

What is it like for you to be in the room with this client or what happens when you see their name on your schedule? *

Presenting Issue (I invite you to consider how this may be adaptive): *

Current symptoms / Risk factors: *

How does this client effectively regulate arousal? *

Which phases of EMDR Therapy are working well? *

Which phases of EMDR Therapy are a struggle? *

Is there something you and / or the client keep “trying” to do that never seems to get the desired result? If so, what is that? *

Please check all relevant fidelity indicators for phases 1 & 2 below *

Spaciousness

Helps client practice and develop Mindful Awareness

Monitors and assesses for dissociation ((ie. DES, MID) and/or other assessment information)

Addresses Culture and Positionality

Considers medical, legal, substance use factors

Clarifies Target Selection and Sequence and discusses with client

Identifies existing resources

Verifies client's ability to auto regulate arousal outside of sessions

Assesses, documents and conceptualizes relevant historical, cultural, family, medical, emotional, social support, or attachment information via the AIP model.

Identifies current life stressors and resources

Completes a Target Sequence Plan that includes past memories, present triggers, future goals

Identifies relevant clinical themes (responsibility / self-worth, safety, control, choices and belonging)

Practices with client, Safe/Calm Place, Container Exercise and / or other stabilization/resource development sufficient to reprocessing.

Provides psychoeducation related to EMDR Therapy, Trauma and the AIP Model

Practices Mechanics such as distance, BLS / DAS method and speed, stop signal

N/A

Required

Please check all relevant fidelity indicators for phase 3 below *

Follows the script

Starts with a clear and specific Target, a "moment in time" (Past memory, present trigger, Future Desired State)

Asks for Picture/image/ or other 5 sense perception

Asks for NC, PC & VOC

Asks for Emotions

Asks for SUD

Asks for Body Sensations

Clarifies NCs and PCs as needed- Self-referential, generalizable, not true (NC) or could be true (PC)

Understands in which category NCs and PCs fall: Responsibility, Safety, Choice & Belonging

Able to recognize when client is not accessing and stimulate activation

Helps client stay focussed and avoids exploring client's responses

N/A

Required

Please check all relevant fidelity indicators for phases 4- 6 below *

Follows the script

Mechanics of BLS / DAS are sufficient

Able to track the depth of processing

Uses Cognitive Interweaves

Therapist stays engaged and is Mindful

Able to know when to go back to target

Able to recognize when processing is completing

Waiting to check SUDs until reprocessing seems near the end

Getting 2 zeros before moving to phase 5

Remembers to check the PC and assist client in crafting a PC related to Responsibility, Safety, Choice & Belonging; Self-referential, generalizable

Gets 2 sevens before proceeding to phase 6

Repeats body scan until no disturbance remains

Checks for feeder memories if somatic disturbance is unremitting

Able to close down and incomplete reprocessing session

N/A

Required

Please check all relevant fidelity indicators for phase 7 below *

Monitors time

Stops processing when arousal is low

Recognizes if Target is "complete" or "incomplete"

Leaves adequate time for stabilization

Supports stabilization and checks for efficacy of intervention

Recognizes need for up-regulating v. down-regulating

N/A

Required

Please check all relevant fidelity indicators for phase 8 below *

Provides structure at the beginning of the session

Asks about symptoms, memories, interactions, last target, checks SUDs

Invites continued reprocessing

Can expand on integration

N/A

Required

Session Note (Feel free to detail the evolution of a particular session if you would like to explore it. Otherwise, write n/a) *

Consultation questions / concerns *

What new information emerged as you completed this form? *

Send me a copy of my responses.

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