EMDR Interest Form

New Mexico Evidence Based Practices
Eye Movement Desensitization and Reprocessing Therapy (EMDR)
EMDR Interest Form

If you have received some training in EMDR but do not currently meet the EMDR qualification standards, or if you have interest in trainings in EMDR, please complete the EMDR Interest Form. The information you provide will be used to guide NMSU Center of Innovation’s future trainings to support providers in achieving the EMDR qualifications required for the EMDR specific rate.

Step 1 of 2

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I. Agency Service Data

Agency Name(Required)

Primary Agency address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Address Medicaid Enrollment ID

Primary County of Service(Required)

Does agency/provider serve additional counties?(Required)

Yes

Additional Counties Served(Required)

Type each county served, separate with comma.

Which populations does/will the EMDR team serve?(Required)

Check all that apply

Children

Adolescents

Adults

Does your agency currently work with/accept referrals for children in state custody (child welfare)?(Required)

Yes

Level of care or service where EMDR is/will be delivered(Required)

Outpatient

School-based

Residential

Community-based

Other

Please describe level of care or service where EMDR is/will be delivered(Required)

Agency is currently funded by/contracted with the following:(Required)

Select all that apply.

MCO- Blue Cross Blue Shield of New Mexico (Centennial Care)

MCO-Presbyterian Health Plan (Centennial Care)

MCO-Western Sky Community Care (Centennial Care)

NM Medicaid Fee for Service

Direct Contract with CYFD

Direct Contract with BHSD

Other

Other funding/contract(Required)

Point of Contact Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

II. Staff Information

List the practitioners at your agency who are interested in becoming qualified to deliver EMDR with the Medicaid EMDR specific rate.

Name of Practitioner #1(Required)

First Last

Email(Required)

Current EMDR Status (check all that apply)(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

No EMDR training

Completed Part 1- Basic Training: 20 hours of EMDRIA approved instruction

Completed Part 2- Basic Training: 20 hours of EMDRIA approved instruction

Completed 10 hours of consultation with EMDRIA approved consultant

Completed non-EMDRIA approved training on EMDR

Anything else you would like to tell us about your training or experience with EMDR?

Anything else you would like to tell us about your interest in EMDR training?

Additional Practitioners interested in this EBP?(Required)

Yes

Name of Practitioner #2(Required)

First Last

Email(Required)

Current EMDR Status (check all that apply)(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

No EMDR training

Completed Part 1- 20 hours of EMDRIA approved instructional material

Completed Part 2- 20 hours of supervised practicum with EMDRIA approved instructor

Completed 10 hours of consultation with EMDRIA approved consultant

Completed non-EMDRIA approved training on EMDR

Anything else you would like to tell us about your training or experience with EMDR?

Anything else you would like to tell us about your interest in EMDR training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #3(Required)

First Last

Email(Required)

Current EMDR Status (check all that apply)(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

No EMDR training

Completed Part 1- 20 hours of EMDRIA approved instructional material

Completed Part 2- 20 hours of supervised practicum with EMDRIA approved instructor

Completed 10 hours of consultation with EMDRIA approved consultant

Completed non-EMDRIA approved training on EMDR

Anything else you would like to tell us about your training or experience with EMDR?

Anything else you would like to tell us about your interest in EMDR training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #4(Required)

First Last

Email(Required)

Current EMDR Status (check all that apply)(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

No EMDR training

Completed Part 1- 20 hours of EMDRIA approved instructional material

Completed Part 2- 20 hours of supervised practicum with EMDRIA approved instructor

Completed 10 hours of consultation with EMDRIA approved consultant

Completed non-EMDRIA approved training on EMDR

Anything else you would like to tell us about your training or experience with EMDR?

Anything else you would like to tell us about your interest in EMDR training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #5(Required)

First Last

Email(Required)

Current EMDR Status (check all that apply)(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

No EMDR training

Completed Part 1- 20 hours of EMDRIA approved instructional material

Completed Part 2- 20 hours of supervised practicum with EMDRIA approved instructor

Completed 10 hours of consultation with EMDRIA approved consultant

Completed non-EMDRIA approved training on EMDR

Anything else you would like to tell us about your training or experience with EMDR?

Anything else you would like to tell us about your interest in EMDR training?

Additional Practitioners in this EBP?

Yes

The limit for the number of practitioners per interest form has been met.

Please email [email protected] if EMDR team is greater than five.

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EMDR Interest Form

I. Agency Service Data

II. Staff Information

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