TREMITIERE Trauma Recovery, LLC
Consent to Treat with EMDR
Eye Movement Desensitization and Reprocessing, (EMDR) therapy is a powerful treatment that NicolleTremitiere, LCSW is trained to utilize for patients presenting with Post Traumatic Stress Disorder, (PTSD) and other traumatic experiences. It is important that Nicolle do a thorough evaluation to determine if you are an appropriate candidate for EMDR which may take up to 3 sessions. If it is determined that you are a candidate for EMDR, we will start the EMDR process which consists of 8 phases of treatment.
Nicolle has used EMDR with all age groups (children, adolescence and adults). There may be some limitations if a patient is cognitively impaired due to a head injury, serious psychiatric illness or if a patient struggles with an intellectual disability that limits understanding. Nicolle cautions that EMDR will work only as well as the patient is cognitively able to participate in the therapeutic process.
Issues Nicolle has treated with EMDR: Nicolle has been using EMDR since 2012 and has completed the required trainings from the EMDR, Institute to safely administer EMDR. Nicolle is in the process of EMDR Certification through the International Association of EMDR Clinicians EMDRIA. currently utilizes EMDR with approximately 20 patients per week. The types of trauma where Nicolle has used EMDR include: Sexual molestation, rape, kidnapping, store hold up, physical assaults, bullying, divorce/separation, fear of water, fear of the dark, intrusive morbid/violent thoughts, infidelity, infertility stress, death of a child, memories of an emotionally abusive parent, attachment issues, irrational fears of a parent dying, making an important decision, death of a friend via suicide, death of a loved one who overdosed, witnessing someone get killed, severe school anxiety, asking for help, bug/reptile phobias, death of a pet, painful breakups, irrational avoidances, perfectionism, extreme anxiety/panic attacks, and workplace stress. Many of these issues have been resolved within 8-15 sessions *. Note: In cases where there was a quick resolution or significant reduction in unwanted symptoms, there were no significant compounding emotional traumas.
Complex PTSD
If it is determined that a client has complex PTSD, where a person is exposed to multiple traumatic incidences over time, it is unlikely that you will experience quick resolution as stated above. Do not allow this to deter you from consideringEMDR.You may have to adjust your expectations however, on the time frame to experience your desired results. If you are experiencing CPTSD, traditional EMDR may not be the correct therapeutic modality to start off with particularly if it is difficult for you to handle intense emotions. Also, if you tend to dissociate in stressful situations you may have difficulty accessing your traumatic memories to be targeted. Nicolle may start out assisting CPTSD patients with strengthen their resources to make sure they can safely tolerate the intense emotions that may accompany EMDR in the future. If this relates to you lets discuss this further.
What is your responsibility in the EMDR process?
First, you need to educate yourself about EMDR to determine if it is a therapy that you think may help you. Nicolle will provide you information for you to explore outside of the session if this form or the TREMITIERE Trauma Recovery is not sufficient. Once you have sufficiently educated yourself please inform Nicolle that you believe that you are ready to participate in EMDR therapy. There are 8 protocols in EMDR therapy; committing to completing all the protocols is important. Sometimes patients may start to feel significantly better prior to completing all 8 protocols and terminate treatment prematurely. This is not advisable as the relief may only be temporary and you could experience a return of uncomfortable feelings and memories. For this reason, you will be asked to sign a statement of understanding that terminating EMDR prematurely is not advisable.
Please initial the following:
Should you find that the feelings that arise during EMDR are too intense, please let Nicolle know immediately so she can work with you on increasing your resources when in emotional distress. ______
You may wait to leave the office if you are feeling unsettled. ______
If you move out of the area, Nicolle is willing to make an appropriate referral to another trained EMDR therapist so you may continue your EMDR therapy. There are trained EMDR therapist in every major city in the US and internationally. Please make sure you take care of yourself. ______
If you fall on unexpected financial hardship and you are unable to afford your sessions, Nicolle may be able to work out a payment plan. Your responsibility is to honor the payment plan we agree on. If you do, you will not be penalized by being sent to collections.______
I will inform my PCP/Psychiatrist about engaging in EMDR therapy. ______
I am willing to commit to completing all 8 protocols of EMDR therapy. ______
I will remain compliant on all medications prescribed to me during EMDR treatment. ______
I am willing and able to contract for safety in between appointments if I experience any thoughts of harming myself or others. *It is ok to call Crisis Intervention if I need to talk. My local Crisis Intervention number is: ______
If am in crisis and need immediate assistance I will call 911 or have a support person take me to the ER. ______
I have discussed all of my concerns regarding EMDR to my satisfaction with Nicolle. ______
I have accepted a copy of this form for my records. ______
By signing this form you are stating that you have read, understand and agree to comply with the recommendations on this form.
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Patient SignatureDate
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Therapist SignatureDate
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