EMDR Supervisor Form

Office of Continuing Education

To be completed by clinical supervisors agreeing to supervise an employee taking the EMDR Basic Therapy Training Course

Your website

If you have any questions or concerns regarding this form please contact sw-ce@buffalo.edu

First name

Last name

Mobile Phone

Professional License(s) e.g., LMSW, LCSW, LMHC, etc. OR degree

Agency and Title

Supervisee Name

Supervisee position/title

Briefly describe the above mentioned participant’s responsibilities, e.g., “assists with client intakes, assessments, and clinical sessions".

I am responsible for the oversight of the above mentioned participant's work.

The above mentioned participant will have the opportunity to practice EMDR techniques with at least FIVE clients during the course.

I endorse the above mentioned participant's application to participate in the EMDR training program.

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