370 Queens Ave, Suite 100
London ON N6B 1X7
Phone: (519) 936-0108 Fax: (519) 936-1028
EMDR CONSULTEE INFORMATION SHEET
Please type directly on this electronic form and email back to consultant.
Name: Agency: Title:
Address: Email Address:
Address Line 1
Address Line 2
City, Province, Postal Code
Home phone: - - Work phone: - - Cell #: - -
Experience as an EMDR Therapist: (make x beside): Beginner Intermediate Advanced
Educational background and degree(s):
Prior intern or work experience in child/adult therapy:
Prior education and/or training in child/adult therapy:
Current type of work:
Theoretical Approaches You Use:
Expectations of Consultation and Learning goals:
Please attach an updated copy of your resume
DR. AMANDA BELL, RSW
370 Queens Ave, London ON N6B 1X6
Phone: (519) 936-0108 Fax: (519) 936-1028
www.amandabell.ca
PROFESSIONAL DISCLOSURE STATEMENT FOR SUPERVISION
Professional Qualifications
I received my Bachelor of Social Work from the University of Western Ontario in 1989, and my Master of Social Work and PhD in Social Work from Wilfrid Laurier University in 1995 and 2012. I am a Registered Social Worker, a Certified Play Therapist and Play Therapy Supervisor and a Certified EMDR clinician. I follow the ethical standards of practice with each of these respective organizations.
Throughout my professional career, I have worked for several child welfare agencies, a feminist counselling agency and in my own private practice, specializing in assessment and treatment services for victimized and traumatized children and their families. I am an expert witness in Ontario Superior Court in the area of intrafamilial sexual abuse and have conducted research in the area of childhood sexual abuse.
I meet continuing education criteria set out by EMDRIA and pay yearly dues and fees to maintain my status as a Certified EMDR psychotherapist and EMDR consultant.
View of Consultation
I believe that consultees cycle through stages on their way to professional growth. I see my job as assisting you to adhere to the Eight Phase protocol of EMDR practice as set out by EMDRIA. I provide ongoing assessment and evaluation of consultees progress. If at any time I have serious concerns regarding your ability to continue to work therapeutically with children, I will speak with you directly and frankly.
Consultation Arrangements
I provide face-to-face consultation, and/or long-distance telephone consultation. In cases of long-distance telephone consultation, you are responsible for long distance telephone charges. Our consultation sessions are 50 minutes in length, unless other arrangements have been made in advance.
Please come prepared to discuss your EMDR sessions of clients whose work you require consultation, indicating your observations of each client’s progress using the 8 phase EMDR protocol and an agenda of other EMDR related question you wish to discuss. I will take notes of our consultations, including suggestions for your work with specific clients. Prior to my providing consultees with a recommendation for EMDRIA certification, I require consultees to provide me with a videotape of at least one EMDR session and a session review summary indicating observations organized by the 8 phase protocol.
I will keep a written record of consultation session. I am generally available by phone for consultation between sessions, as needed. I can be reached at 519-936-0108 or by email, .
Please ensure that your employer (where applicable) and any clients for whom you are seeking EMDR consultation are aware that you are currently receiving EMDR consultation with myself. This should include a consent document indicating client’s consent for you to share non-identifying, confidential information with myself. If you are videotaping, notify your clients of this as well, and obtain the appropriate written consent. I will provide you a copy of my curriculum vitae, upon request, which you may copy and provide to any clients who desire to know more about my training and experience.
Evaluation Procedures
Ongoing review of your work will occur during scheduled consultation sessions. This will be in the form of verbal comments and feedback. When and if skill deficit is identified, I will provide training and/or recommend other options for remediation of that skill. If at any time I believe I will not be able to recommend you for certification, I will discuss this with you at the earliest appropriate time.
Fees and cancellation
Fees are $125 plus HST per 50 minute session and $100 plus HST / 2 hour group consultation session unless otherwise negotiated. Cash or personal checks are acceptable. Telephone calls, attendance at meetings, and correspondence are billed accordingly. This fee is due at the end of each consultation session. Your session is reserved for you. In the event that you will be unable to keep an appointment, please notify me at least 48 hours in advance, so that someone else may utilize this time. In the absence of your notification, you will be billed for the missed session.
______
Dr. Amanda Bell Date
______
Consultee Date
CONTRACT: EMDR CONSULTATION
The consultant agrees to the following:
1. To provide EMDR specific consultation on cases presented
2. To be well prepared to provide consultation on cases as agreed upon for each session
3. To role model professional conduct and adherence to the 8 Phase EMDR protocol
4. To respect boundaries and confidentiality of the consultee
5. To keep a written record of consultation hours
6. To provide consultee with receipts for paid consultation fees
7. To ensure that the consultee signs the necessary confidentiality and consent forms
8. To act as a reference for the consultee as requested
9. To continue with professional education and training
______
Signature of Consultant Date
The consultee agrees to the following:
1. To abide by a professional standard of conduct as outlined by my profession’s Code of Ethics, i.e. Social Work Association, Psychological Association
2. To maintain legal liability insurance (if not already covered by employer) and to provide a copy to the consultant
3. To ensure that the necessary confidentiality and consent forms are signed for each case presented in consultation
4. To be well prepared to review cases as agreed upon for each consultation session
5. To communicate learning needs directly to the consultant
6. To take responsibility for continuing professional growth and development
7. To remunerate the consultant at an agreed rate of $125 plus HST per 50 minute session and $100 plus HST / 2 hour group consultation session
8. To remunerate the consultant $125 plus HST per 50 minute session and $100 plus HST / 2 hour group consultation session for canceled consultation time unless 24 hours notice is provided
9. To provide payment for services upon receipt of invoices
______
Signature of Consultee Date
DR. AMANDA BELL, RSW
Certified EMDR Therapist
370 Queens Ave, Suite 100, London ON N6B 1X6
This letter is to document that the below listed party has entered into a Consultation agreement on today’s date that provides the individual with consultation hours required towards EMDR certification with EMDRIA.
This agreement and the listed party’s payment for consultation hours does not guarantee a recommendation for certification with EMDRIA or a recommendation to any other credentialing agency/organization.
The individual listed agrees to this consultation with the understanding that
Dr. Bell does not have full access to treatment plans and progress notes and assumes no liability for the clinical decisions made by the individual seeking consultation. Under this agreement the supervisee is encouraged to follow the recommendations made during consultation. However, it is required that the consultee follow the laws, ethics, and guidelines that govern her/his profession.
It is also understood that the information shared during consultation is for educational and information purposes only and does not constitute legal advice. Dr. Bell makes no claims, promises or guarantees regarding the information exchanged during consultation as legal representation. Legal advice is specific to the circumstances of each situation and exchanges during consultation in no way replaces or acts as a substitute for the advice of competent legal counsel.
I agree to and understand the above.
Consultee’s Signature:______Date: ______
Consultant’s Signature: ______Date: ______
(Adapted from Krull, 2004)
AUTHORIZATION TO RELEASE INFORMATION
I,
(CHILD'S LEGAL GUARDIAN)
OF
(ADDRESS)
HEREBY AUTHORIZE TO
(THERAPIST'S NAME)
RELEASE INFORMATION CONCERNING
(CHILD'S NAME AND DATE OF BIRTH)
TO DR. AMANDA BELL FOR THE PURPOSES OF CLINICAL CONSULTATION.
I UNDERSTAND THAT ONLY INFORMATION RELEVENT TO MY CHILD'S
TREATMENT WILL BE SHARED WITH DR. AMANDA BELL.
I ALSO HEREBY AUTHORIZE
(THERAPIST'S NAME)
TO VIDEOTAPE MY CHILD'S COUNSELING SESSIONS AND TO SHARE THESE
VIDEOS WITH AMANDA BELL FOR THE PURPOSES OF CONSULTATION. IT
IS UNDERSTOOD THAT THESE VIDEOS WILL BE USED FOR CONSULTATION
PURPOSES ONLY AND THAT THEY WILL BE RETURNED TO
(THERAPIST'S NAME)
FOLLOWING CONSULTATION . I AFFIRM THAT I AM THE LEGAL GUARDIAN
OF AND THAT I UNDERSTAND THE ABOVE CONDITIONS.
(CHILD'S NAME)
LEGAL GUARDIAN’S SIGNATURE ______
DATE ______
DECLARATION OF PROFESSIONAL LIABILITY INSURANCE
This signature is a declaration that I,
(name of supervisee)
have current professional liability insurance with
Insurance Company
or my place of work at
Signature of Consultee: ______Date: ______
(Please attach a copy of your professional liability insurance)
CONSULTATION HOURS
Consultant's name: Dr. Amanda Bell, RSW
Consultee's name:
DATE / HOURS / ACTIVITY