Group Consultation Contract Group Consultation Information This agreement outlines the expectations regarding group consultation toward EMDRIA Certification in EMDR. Consultation groups for clinicians seeking EMDRIA Certification are structured as follows: According to EMDRIA requirements, the maximum group size for EMDRIA Certification consultation is 8 consultees. I prefer to run a smaller group and the maximum number of participants I allow in the group at any one time is 4 consultees. I have chosen to limit the group size to 4 consultees so that everyone in the group has an opportunity to present case material during each meeting. Consultees must attend 10 sessions and present current/recent case material on all 8 Phases in order to obtain documentation for 10 hours of group consultation toward EMDRIA Certification. Consultees are expected to come prepared to present case material, complete with notes on that case. Cases will be presented using the EMDR case presentation form (I will provide this to you as I want those who participate in the group to all use the same form). Not all group participants are able to present full cases in every group meeting. My goal is that each participant will discuss some aspect of their clinical work in each meeting. You may schedule a case presentation in advance of the group meeting to help ensure the opportunity to present a full case. Do not include any information that will identify the case you are presenting. The group will meet for 60 minutes and meetings may be held in person or at my office (115 E. Montgomery St., Gaffney, SC 29340). Format Session Session 1: Introductions Payment in full is due at or prior to Session 1 (cash, check, or credit card). Read/review Chapter 1 from Getting Past Your Past, by Francine Shapiro. Discuss informed consent for EMDR, introducing EMDR to clients, and your intake interview/process. Sessions 2-10: Phase-focused questions and review (20 minutes) Case Presentation 1 (20 minutes) – on indicated Phase(s) Case Presentation 2 (20 minutes) – on indicated Phase(s) All case presentations should include (at minimum) the information indicated on the Case Presentation Sheet provided at Session 1, with detailed information regarding the Phase(s) assigned. The following items are due (sent via email, fax, or mail) at least 1 week prior to Session 1: This agreement, signed and dated. A copy of your EMDR basic training completion certificate (If not already sent for individual consultation). Consultee InformationFull Name and degree:(Required) License type and number:(Required) Preferred mailing address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred Phone:(Required)Email Address:(Required) Name & address of work setting:(Required)Number of clients you see per week:(Required) Are you able to utilize EMDR in your work setting?(Required) Yes No Are there other therapists utilizing EMDR in your work setting?(Required) Yes No Types of clients and presenting issues with which EMDR will be utilized:(Required)If you have a Supervisor who is providing supervision towards licensure, please provide his/her name and contact information. Consultant and Supervisor may speak briefly during consultation, and as needed.(Required)Prior to learning EMDR, which psychotherapy models were you typically utilizing?(Required)How long have you been practicing therapy?(Required) How long have you been practicing EMDR?(Required) With what aspects of EMDR are you most comfortable?(Required)What aspects of EMDR are currently most difficult for you?(Required)Fees Consultation groups for clinicians seeking EMDRIA Certification meet 10 times for 60 minutes each for a total fee of $75 paid at or before the first group. Consultation groups for clinicians not seeking certification but additional skill development meet as needed for 60 minutes for a total of $50 paid at or before group. Please send your completed consultation agreement to me at least one week prior to the first group consultation session. I have read and understand and agree to the above conditions and expectations.Choose Your Certification Type(Required) EMDRIA Certification ($75) Skill Development ($50) Total Credit CardPlease check your Square settings.Consultee Name(Required) Signature(Required)Date(Required) MM slash DD slash YYYY Consultant Name(Required) Signature(Required)Date(Required) MM slash DD slash YYYY
