Student Form

Name *
Name of Graduate Program, degree, and major being pursued:
Internship Setting and Mailing Address:
Internship Clinical Supervisor’s Name, Title, and Phone Number:
Briefly describe the population the served in the internship setting:
Briefly describe your job:
How many psychotherapy cases do you see and with what frequency?
What psychotherapy method(s) have you been trained in?
Do other clinicians in your agency currently use EMDR with clients? If yes, please describe:
Is your supervisor familiar EMDR? Are they supportive of your intention to use of this psychotherapy approach with clients in this setting?
By Typing Name below, I confirm the above information is accurate: