EMDR Consultation Interest Form

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I am so excited that you are interested in working with me for EMDR consultation. Please complete this form to help me get to know you a little better before we begin working together. Once I receive the form I will reach out to you and schedule a phone call.

Email *

Full Name and pronouns *

Phone number

License type, state, number, and expiration date *

When did you complete EMDR basic training and with whom? *

Was the training you completed EMDRIA approved?

Yes

I am not sure

Clear selection

What are your goals for consultation?

What population(s) do you work with and in what setting? *

What are your strengths as an EMDR therapist? *

What areas would you like to grow in as an EMDR clinician? *

What else is important for me to know about you? *

Investment:

EMDR Consultation is an investment for your professional growth. As a consultant in training I am dedicated to providing you with the best support possible to help you in your work serving clients. The rates for my consultation services are: $50 for a 120 minute group and $60 for a 60 minute individual. You will be billed when services are rendered unless otherwise discussed and agreed upon in writing.

I understand and am able to commit to paying for consultation services

I am really struggling financially and need to hear about sliding scale options

Required

EMDRIA requirements for certification regarding consultation:

You must complete 20 Hours of Consultation by an EMDR Consultant

The 20 hours of consultation must have been completed within the last 5 years.

If you have received consultation from more than one EMDR Consultant, you will need documentation from each one.

At least 10 of the hours must be obtained through individual, EMDR-focused consultation. The remaining 10 hours may be obtained through small group consultation. Consultation groups cannot exceed more than eight participants at a time.

EMDR Consultants-in-Training can provide up to 15 hours of consultation. The remaining five hours must be provided by an EMDR Consultant.

Only consultation hours received after completion of an EMDRIA Approved EMDR Training program can be applied towards this requirement.

I will provide documentation regarding attendance after our meetings if you need it for certification. As a consultant in training I am unable to provide a letter of recommendation for certification.
*

I understand the above information and have no concerns

Other:

Required

Consultation Options/Goals

2nd Tuesdays 12:00pm -2:00pm Group

I am only interested in individual consultation

I am interested in group and individual consultation

Send me a copy of my responses.

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