Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Mental Health Degree *

(highest degree obtained in a mental health field)

Bachelor's degree

Master's degree

Ph.D

Psy.D

Confidentiality - Practicums *

During practicums you and your fellow participants will be rotating through clinician, observer, and client roles. As in your therapeutic practice, confidentiality is very important throughout this training. You will be working with fellow clinicians during practicum and sharing personal information. Information that is shared at training is to be kept confidential to ensure safety of all participants, including yourself.

I understand and agree to maintain participant confidentiality

Confidentiality - Consultation Cases *

During group consultation you will be sharing client experiences as you begin to use EMDR therapy. Confidentiality is paramount and required on all cases discussed, relative to discussions held and cases reviewed. Signed releases by the participant’s clients are required on all cases discussed in meetings in your medical files for clients (please ensure this is included on any policy forms that describe confidentiality for your practice). It is the participant’s responsibility to maintain the release in the client’s file. When we share cases in group consultation, client names and identifying information are to be protected and not included on consultation forms. ***You must be able to practice EMDR therapy with clients following Part 1 of training.

I understand and agree to maintain client confidentiality. I will be able to use EMDR processing in my clinical practice with clients.

Prerequisites for EMDR Therapy Training *

All participants in the training must be licensed or on a licensing track. These requirements outline the minimum eligibility requirements to take an EMDRIA Approved EMDR Therapy Training. Who can take the training: Licensed Health Professionals - Medical Doctors licensed in their province or state who have training in mental health - Registered Nurses who have a Master’s Degree with a specialization in mental health (psychiatric mental health nursing) and who are licensed in their province or state - Mental health clinicians who have at minimum of a Master’s Degree in a mental health field (Counselling, Marriage and Family Therapy, Psychology, Psychotherapy, Psychiatry, Social Work) or related mental health discipline and be licensed to practice through a professional organization or regulation body that includes a code of ethics and public protection. Pre-Licensed Mental Health Professionals - Clinicians who are actively pursuing a mental health license through their provincial, state, or national regulating body while working under a licensed supervisor (e.g., intern, associate). Graduate Students - Current enrolment in a Master’s or Doctoral program in a mental health field (Counselling, Marriage and Family Therapy, Psychology, Psychotherapy, Psychiatry, Social Work). Core graduate academic coursework must have been completed (80% of coursework) and have completed or are currently in the practicum/internship portion of their graduate program. First year graduate students are not eligible. Graduate students must be on a licensing track and working under the supervision of a licensed mental health clinician. *Graduate students are required to provide documentation (unofficial transcript, practicum or internship details, and a letter from their supervisor that includes their support for taking the training, their license information and number, stating that you will be seeing clients under their supervision and you have access to clients you can use EMDR Therapy with). If you are unsure that you meet these pre-requisites, please contact the training provider at ElevateEMDR@gmail.com.

I meet the prerequisites for EMDR training

EMDRIA Requirements *

EMDRIA, the training organization that provides guidelines for EMDR Training, indicates that a participant cannot miss more than 15 minutes per day of training. Should more time be missed, the participant will need to attend the portion that was missed at a future training. Time to complete training: Participants have 12 months to complete training which includes: Part 1 and 2 of training (20 instructional hours, 20 practicum hours), 10 group consultation hours, the EMDRIA Learning Assessment, and have seen at least one client for phases 3-6. All participants are welcome at training, so long as the prerequisites are met, regardless of an individual’s sexual orientation, gender identity, race, ethnicity, culture, religion, or disability. Participants will be supported throughout training to best help them learn and integrate the material. For further discussion, please contact Dr. Penner Hutton.

I agree and understand the EMDRIA requirements

Documentation required *

I will send a copy of my mental health degree and registration to info@elevateemdr.ca or upload to this form. If I am a student or pre-licensed, I will contact info@elevateemdr.ca to obtain a form for my supervisor to sign.

I understand that I need to submit the required documentation

Required reading: EMDR textbook *

EMDRIA requires that you read the following. The textbook is not provided by Elevate EMDR Academy and you will need to acquire a copy of the following book and read it for training. Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). New York: Guildford Press. Part 1 of training focuses on Chapters 1 - 8.

I agree to obtain the textbook and read it in its entirety.

Agreement to participate in practicums *

Practicum is a major component of training. This includes your engaging in your own processing work. Because this training includes an experiential component, you must be prepared to work on your own personal issues in practice sessions. We ask participants to think ahead about something that would be suitable for processing work (e.g., symptom of anxiety for learning EMDR at training; a specific memory; a negative belief that doesn’t hold too much charge). Any memories that you process at training need to be a SUDs < 5 (on a scale of disturbance where 1 = neutral or not at all distressed and 10 = the worst you can imagine). We want to emphasize that this training is not the place to address issues that are very disturbing as this is a training setting and not personal therapy. You will be choosing a symptom to use for treatment planning purposes (e.g., anxiety, a negative self belief) and will be creating a treatment plan of past memories and present triggers linked to the symptom in Part 1 of training. You will be responsible for choosing memories and triggers from your treatment plan that are SUDs < 5. Examples of memories that could be appropriate for this setting are a childhood memory about a friend with whom you had a conflict, a memory of being lost in a store for a few minutes, or a memory about a disagreement you had with an adult friend or coworker. A past memory about performance anxiety or anxiety about starting a new job. Please avoid memories that are related to your family of origin. Please talk to the trainer prior to the beginning of the training should you have any concerns regarding practicum components (e.g., if it is not currently safe for you to engage in processing). For the purpose of training, you are only absolutely required to be in the role of clinician during practicum to practice and develop new skills. We can discuss options if you feel you are unable to safely be in the client role.

I am able to be in the client role during practicums and agree to choose targets for reprocessing that are a SUDs of 5 or less in disturbance. I will inform the trainer if this changes or if I am feeling dysregulated at training.

Group Consultation *

The 10 hrs. are divided into 4 group consultations of 2.5 hrs. each. An EMDRIA Approved Consultant (or consultant-in-training) will be facilitating group consultations and is included as a component of training. Participants will have to complete 1 group consultation session after part 1 of their training and 3 group consultation sessions after part 2 of their training. Times/dates will be provided by Elevate EMDR Academy and groups will be conducted over Zoom. You will sign up for and commit to a time slot. Should you need to cancel or reschedule, you need to provide 24 hours notice. You will complete a consultation form for each consultation and email it to your consultant 3 days prior to the consultation date.

I understand that I am required to complete 10 hours of group consultation. Should I not show up for a consultation or cancel without providing at least 24 hours notice, I will speak with the trainer and arrange for an additional group session at an additional cost of $100 Cdn.

Accommodation and Grievance Policy *

Grievances are only accepted in writing and will be handled within ten business days. Please email your grievance to info@elevateemdr.ca If you require specific accommodation, please make your request in writing 30 days before the 1st day of training for Part 1. Email your request to info@elevateemdr.ca. Elevate EMDR Academy cannot ensure accommodations without adequate prior notification. *Conflict of interest for this program: There is no known conflict of interest for this program. Elevate EMDR Academy has not received any financial support for this program or its contents and will not receive any financial support before or during this program. Elevate EMDR Academy will disclose any potential conflicts at the beginning of the training.

I agree to provide grievances in writing. I agree to send requests for accommodation 30 days prior to Part 1 of training

Refund Policy *

Refunds on purchased trainings are available until 30 days before the first day of training. There are no refunds after this date. No refund will be issued once the training begins. $200 of the total tuition is non-refundable (processing fee). Elevate EMDR Academy offers two to three training sessions per a year (in person or online). It is important to cancel as soon as you know that you cannot attend. Should you need to cancel within 30 days of a training, options will be discussed for transferring the registration fee to a different training. Documentation to justify a transfer will need to be provided by yourself. A $200 transfer fee will apply and refunds on transferred trainings will not be provided. Refunds and EMDR training certificates are not available to participants who miss portions of training i.e. missing a portion of a training day or whole training days; missing group consultation times. 48 hours prior to the first day of training (Part 1), transfers are no longer available and attendees will lose their registration if they are no longer able to attend the training.

I understand the refund policy and agree to the transfer fee

Cancellation of training *

This training may be canceled or postponed 30 days before its date due to under-enrolment or other unforeseen circumstances (e.g., location becomes unavailable). Training may also be cancelled due to presenter illness, natural disaster (a flood, earthquake, tsunami, wildfire, or other major incidents), or other unforeseen circumstances that may arise. Dates may be rescheduled or participants may be transferred to the next training session or receive a full be refunded. Elevate EMDR Academy reserves the right to cancel the EMDR basic training at any time. Should this happen, learners will receive a full refund or a credit/transfer to a later training will be offered. Credit card, bank fees, transaction fees, or processing fees etc. will not be covered by Elevate EMDR Academy.

I understand the reasons provided for cancellation of training