Supervisor Signoff Agreement

*This form is to be completed and submitted to Miranda Counseling at or before the training for anyone who is under supervision towards licensure.

This includes graduate interns (must be in 2nd year or practicum level to attend training), or post-graduate professionals under supervision toward independent level licensure

Attendee Name

Attendee License #/State (If Applicable)

Month/Year/City of the training requested:

Supervisor Email

Supervisor License #/Type/State

RELEVANT INFORMATION Supervisor, please check the boxes below to acknowledge:

I understand that my supervisee will be practicing EMDR Therapy and related procedures during the training.

Yes I understand.

I understand that to receive the most benefit from the course my supervisee will need to practice EMDR Therapy with clients during the follow-up consultation period (0-12 months after the training.)

Yes I understand.

By entering my name below, I give my consent for my supervisee to attend the training.

Yes I understand.

I acknowledge that my supervisee has completed their Masters Level work and is pursuing Licensure OR is a Graduate Student in the Practicum portion of their curriculum.

Yes I acknowledge.

Supervisor Name

You may also download a PDF version of this agreement. It can be completed and then emailed here.

Save more! Register for EMDR and Play Therapy Training + 1 Day Refresher, Get $50 OFF of EACH DAY! Coupon Code: Synergy50

Supervisor Signoff Agreement

Contact Us

Subscribe to our Newsletter

Therapy Services for Children and Adults

Navigation

Contact Us

Get Connected