Cautions Concerning EMDR Informed Consent

Cautions Concerning EMDR Informed Consent

1. I realize I have the ego strength to begin EMDR. I know how to breathe and relax when I feel stress. I understand the processing could continue between sessions, and I am ready to deal with the disturbance/trauma that may be releasing from my nervous system-including but not limited to dreams, tiredness, agitation, etc. I know how to keep a “detached perspective”, and I am willing to be diligent in following a relaxation response whenever I feel nervous or emotional between sessions. I will maintain a stress reduction response and go to my “safe place” whenever appropriate. I recognize the need for a support system while going through my “EMDR experience”.

2. I understand that processing may continue between sessions. I understand that I may feel tired or “out of sorts”, including experiencing a mental “fuzziness” which could prevent me from having the concentration I need for important tasks. I understand it is important not to schedule an EMDR session during a period of time when would need to stay clear, focused, and on-task. I agree to keep a note or log of any disturbing, different, or dream experience (3 D’s) I encounter after an EMDR session. I agree to bring that information to my next session.

3. I acknowledge I have the physical strength to begin EMDR. I recognize that high blood pressure, medications, or eye muscle strength, age factors, pregnancy factors and any other medical conditions which would be stressed by emotional releases/experiences have been considered. I agree to speak with my doctor if I have a question or concern about any medical condition including where (hospital setting) and when an EMDR session would be appropriate. I give my doctor permission to speak with this therapist, Candace J. Hembree, LPC, if the need arises.

4. I understand that past traumas that are involved in current court cases have been considered. I understand EMDR may not be appropriate if there is any litigation involving one of my issues or traumas because EMDR could change perspective/ detail, and could change the emotional impact of the memory. I realize how that could impact a court case.

5. I understand there needs to be caution involving dissociative disorders. I agree to confide in my therapist if I have ever been diagnosed with a dissociative disorder. If I suspect that I dissociate, I will complete a DES form before my first session. If I have concerns regarding this issue, I will discuss them before beginning EMDR, and I will share information regarding my dissociative traits before beginning EMDR.

6. I understand that if I have a pre-disposition to certain conditions, the impulse to engage in this condition could be increased during EMDR sessions. If I am pre-disposed to alcohol, drugs, eating, nail-biting, etc., the inclination to participate in those activities could increase with EMDR. Instead, I agree to use the relaxation techniques I learned, use my supports, and if necessary call my therapist for an emergency EMDR session or phone session, whichever is appropriate. I understand there will be a charge for phone sessions.

7. I understand it is imperative never to attempt EMDR on myself or others. I understand that special training is issued to licensed clinicians trained in EMDR and EMDR could be dangerous in the hands of the untrained.

8. I understand there are no guarantees and there may be situations where EMDR will not work the way I expect it to. I understand if this occurs, the possible causes will be explored and discussed.

I have read the above 8 cautions carefully and have discussed them with my therapist. I understand the above 8 cautions and I am willing to “expect the unexpected” as well as the possibility that nothing may happen. Having considered all of this, I agree to begin EMDR and give my informed consent to have Candace J. Hembree, LPC facilitate my EMDR sessions.

Client Signature/Guardian Date

EMDR Readiness Questionnaire

(ERQ)

Name:

Date:

Please mark and X under to what extent the item apply to you:

Not at all Rarely Sometimes Often Always

I have a permanent place to live.

My basic needs are met.

I have enough money to pay for basic needs.

I live in a safe environment.

Not at all Rarely Sometimes Often Always

I have a spouse or partner I confide in.

I have family to talk to.

I have close friends or co-workers I confide in.

I am involved in community organizations.

I am involved in support groups.

I make friends easily.

Not at all Rarely Sometimes Often Always

I am able to identify my feelings.

I know why I feel the way I do.

I recognize how the past affects my feelings now.

When I grew up, it was safe to express my feelings.

My parents or caretakers over-reacted emotionally.

I am able to express my feelings appropriately those I trust.

When appropriate, I am able to show feelings.

I am able to accept and tolerate intense feelings.

Not at all Rarely Sometimes Often Always

If I show feelings, I’m afraid others won’t like me.

I alternate feeling love and hate for the same person.

My feelings change rapidly and unexpectedly.

I overreact to people and situations.

I have a short fuse.

I feel empty.

Presently, I feel depressed and suicidal.

In the past, I have gotten so depressed that I felt suicidal.

Presently, I feel so angry I feel like hurting others or things.

In the past, I’ve hurt others or things.

When I feel bad, I act impulsively in harmful ways.

When I feel bad, I hurt my body.

Not at all Rarely Sometimes Often Always

I need to be in control and want things my way.

I tolerate changes well.

I am flexible.

Not at all Rarely Sometimes Often Always

I like myself.

I am confident.

I trust myself.

I feel people are out to get me.

I hear or see things others do not.

Not at all Rarely Sometimes Often Always

I share my innermost thoughts/feelings with those I trust.

I get defensive when questioned about my past.

Not at all Rarely Sometimes Often Always

I have lapses in memory.

I have bodily symptoms that physicians can’t explain.

I view the world as strange and unreal.

I feel like I am an observer of my thoughts and body.

I feel like I am in a dream.

I hear voices inside my head.

I have feelings that come out of the blue without explanation.

I cope with feelings by going away inside.

I cope with feelings by pushing them down.

Not at all Rarely Sometimes Often Always

A/D

Presently, I use alcohol/drugs to cope.

Alcohol/drugs have a negative impact on my life.

I have used drugs/alcohol to cope in the past.

Alcohol/drugs have had a negative impact in the past.

Indicate Yes or No for the following items…

SMI

I use meds for anxiety, depression or hearing voices.

In the past, I’ve used meds for these reasons.

I have been hospitalized for emotional/psychiatric reasons.

I have received treatment for alcohol/drug abuse.

I have attempted suicide.

I have heart problems.

I have high blood pressure.

I have eye problems.

I have respiratory problems.

I have neurological problems.

I have a seizure disorder.

I am pregnant.

Any other medical conditions?

I am or may become involved in legal action.

I have been in prison.

I have been arrested.

I have been in a physical fight in the past year.

I have attempted/committed homicide.

I often have to fight to defend my rights.

I often have to lie to get by.

Extra space if needed for YES responses: