Limits of Service. It is expressly agreed that no supervision or employment relationship exists between Consultant and Consultee. Consultee – or Consultee’s legally mandated supervisor if any – remains solely responsible for services provided to Consultee’s clients. Consultant will provide information based on research, scholarly consensus, and Consultant’s experience for Consultee to consider. Consultee will rely on his or her own judgment in offering specific psychotherapy services to Consultee’s clients and will not state or imply he or she is following guidance from Consultant. EMDRIA Group Consultation hours only: This group is structured to provide only group consultation hours toward EMDRIA Certification. I will actively share my EMDR case work experience in each session. After the 6th group session, Dr. Leeds will provide documentation of group consultation hours for the time I spend in these sessions. Conflict resolution: A friendly atmosphere is advocated and fostered in the consultation process. If differences arise, both Dr. Leeds and I commit to resolving any issues in a professional and mutually beneficial manner, including, if necessary, bringing in a third party. Dr. Leeds and I each agree to abide by the code of ethics of the professional organization(s) to which we belong. Logistics: The consultation group will meet via Zoom for 6 sessions Friday Series: January 7, February 4, March 4, April 1, May 6, June 3, 2022. Call times for the Friday series: Pacific: 9:00 – 11:00 AM; Mountain: 10:00 – 12:00 Noon; Central: 11:00 – 1:00 PM; Eastern: 12:00 – 2:00 PM The consultation group includes a maximum of eight members. I will be given in advance a series of Zoom meeting invitations that allow options for access by the Zoom application or telephone. I agree to securely share case files via a free account on Xxx.xxx. [Initial here] To keep consultation fees reasonable, I understand I will not be given an alternate session nor a refund if I am unable to attend one or more of the sessions for which I am registered. Confidentiality: [Initial here] As a member of this consultation group, I agree to notify clients and obtain their written consent to my seeking consultation without specifically identifying the name of my consultant. I will alter identifying information in any case material I present. I will treat as confidential all case material presented by others in this group. Work samples: When possible, I will provide written case summaries and/or near verbatim transcript of reprocessing sessions when presenting individual cases. A case summary form and near verbatim summary guide is available from Dr. Leeds website Resources page at: xxxxx://xxx.xxxxxxxxxxxxxxxx.xxx/resources [Initial here] I agree to pay the consultation group fee in full as described below even if I miss one or more of the sessions. No make-up sessions are provided. Switching group series is not permitted. I confirm and accept the dates below for the Friday Series by checking my choice of fee arrangements: Friday Series: January 7, February 4, March 4, April 1, May 6, June 3, 2022. Standard fee I agree to pay $450 for this consultation group series in full in advance by check. Or I authorize Dr. Leeds to charge my credit card below for six automatic payments of $80 each month the week of each session as listed above for a total of $480. Agency discount I request the 25% fee reduction available to clinicians employed in Community Mental Health and small nonprofit agencies. With this signed agreement I include a letter on agency letterhead confirming employment 30 hours or more per week. I agree to pay $337.50 for this consultation group series in full in advance, by check. Or I authorize Dr. Leeds to charge my credit card $60 per month for a total of $360. Credit Card Information Check one: ❏ MasterCard ❏ Visa ❏ Discover ❏ American Express Card number: Expires 3- or 4-digit Security Code Name on card: Signed: Date: Credit Card Billing Address: City: State: Zip: Country: Contact Information Mailing Address: City: State: Zip: Country: Phone: Fax: E-mail: Please print legibly. By signing below, I indicate my acceptance of this Group Consultation Agreement: Print Name: Signed: Date:
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Limits of Service. It is expressly agreed that no supervision or employment relationship exists between Consultant and Consultee. Consultee – or Consultee’s legally mandated supervisor if any – remains solely responsible for services provided to Consultee’s clients. Consultant will provide information based on research, scholarly consensus, and Consultant’s experience for Consultee to consider. Consultee will rely on his or her own judgment in offering specific psychotherapy services to Consultee’s clients and will not state or imply he or she is following guidance from Consultant. EMDRIA Group Consultation hours only: This group is structured to provide only group consultation hours toward EMDRIA Certification. I will actively share my EMDR case work experience in each session. After the 6th group session, Dr. Leeds will provide documentation of group consultation hours for the time I spend in these sessions. Conflict resolution: A friendly atmosphere is advocated and fostered in the consultation process. If differences arise, both Dr. Leeds and I commit to resolving any issues in a professional and mutually beneficial manner, including, if necessary, bringing in a third party. Dr. Leeds and I each agree to abide by the code of ethics of the professional organization(s) to which we belong. Logistics: The consultation group will meet via Zoom for 6 sessions Friday Series: January 7July 2, February 4July 30, March 4September 3, April October 1, May 6November 5, June December 3, 20222021. Call times for the Friday series: Pacific: 9:00 – 11:00 AM; Mountain: 10:00 – 12:00 Noon; Central: 11:00 – 1:00 PM; Eastern: 12:00 – 2:00 PM The consultation group includes a maximum of eight members. I will be given in advance a series of Zoom meeting invitations that allow options for access by the Zoom application or telephone. I agree to securely share case files via a free account on Xxx.xxx. [Initial here] To keep consultation fees reasonable, I understand I will not be given an alternate session nor a refund if I am unable to attend one or more of the sessions for which I am registered. Confidentiality: [Initial here] As a member of this consultation group, I agree to notify clients and obtain their written consent to my seeking consultation without specifically identifying the name of my consultant. I will alter identifying information in any case material I present. I will treat as confidential all case material presented by others in this group. Work samples: When possible, I will provide written case summaries and/or near verbatim transcript of reprocessing sessions when presenting individual cases. A case summary form and near verbatim summary guide is available from Dr. Leeds website Resources page at: xxxxx://xxx.xxxxxxxxxxxxxxxx.xxx/resources [Initial here] I agree to pay the consultation group fee in full as described below even if I miss one or more of the sessions. No make-up sessions are provided. Switching group series is not permitted. I confirm and accept the dates below for the Friday Series by checking my choice of fee arrangements: Friday Series: January 7July 2, February 4July 30, March 4September 3, April October 1, May 6November 5, June December 3, 20222021. Standard fee I agree to pay $450 for this consultation group series in full in advance by check. Or I authorize Dr. Leeds to charge my credit card below for six automatic payments of $80 each month the week of each session as listed above for a total of $480. Agency discount I request the 25% fee reduction available to clinicians employed in Community Mental Health and small nonprofit agencies. With this signed agreement I include a letter on agency letterhead confirming employment 30 hours or more per week. I agree to pay $337.50 for this consultation group series in full in advance, by check. Or I authorize Dr. Leeds to charge my credit card $60 per month for a total of $360. Credit Card Information Check one: ❏ MasterCard ❏ Visa ❏ Discover ❏ American Express Card number: Expires 3- or 4-digit Security Code Name on card: Signed: Date: Credit Card Billing Address: City: State: Zip: Country: Contact Information Mailing Address: City: State: Zip: Country: Phone: Fax: E-mail: Please print legibly. By signing below, I indicate my acceptance of this Group Consultation Agreement: Print Name: Signed: Date:
Appears in 1 contract
Limits of Service. It is expressly agreed that no supervision or employment relationship exists between Consultant and Consultee. Consultee – or Consultee’s legally mandated supervisor if any – remains solely responsible for services provided to Consultee’s clients. Consultant will provide information based on research, scholarly consensus, and Consultant’s experience for Consultee to consider. Consultee will rely on his or her own judgment in offering specific psychotherapy services to Consultee’s clients and will not state or imply he or she is following guidance from Consultant. EMDRIA Group Consultation hours only: This group is structured to provide only group consultation hours toward EMDRIA Certification. I will actively share my EMDR case work experience in each session. After the 6th group session, Dr. Leeds will provide documentation of group consultation hours for the time I spend in these sessions. Conflict resolution: A friendly atmosphere is advocated and fostered in the consultation process. If differences arise, both Dr. Leeds and I commit to resolving any issues in a professional and mutually beneficial manner, including, if necessary, bringing in a third party. Dr. Leeds and I each agree to abide by the code of ethics of the professional organization(s) to which we belong. Logistics: The consultation group will meet via Zoom for 6 sessions Friday Saturday Series: August 13, September 17, October 15, November 12, December 10, 2022 & January 714, February 4, March 4, April 1, May 6, June 3, 20222023. Call times for the Friday series: Pacific: 9:00 – 11:00 AM; Mountain: 10:00 – 12:00 Noon; Central: 11:00 – 1:00 PM; Eastern: 12:00 – 2:00 PM The consultation group includes a maximum of eight members. I will be given in advance a series of Zoom meeting invitations that allow options for access by the Zoom application or telephone. I agree to securely share case files via a free account on Xxx.xxx. [Initial here] To keep consultation fees reasonable, I understand I will not be given an alternate session nor a refund if I am unable to attend one or more of the sessions for which I am registered. Confidentiality: [Initial here] As a member of this consultation group, I agree to notify clients and obtain their written consent to my seeking consultation without specifically identifying the name of my consultant. I will alter identifying information in any case material I present. I will treat as confidential all case material presented by others in this group. Work samples: When possible, I will provide written case summaries and/or near verbatim transcript of reprocessing sessions when presenting individual cases. A case summary form and near verbatim summary guide is available from Dr. Leeds website Resources page at: xxxxx://xxx.xxxxxxxxxxxxxxxx.xxx/resources [Initial here] I agree to pay the consultation group fee in full as described below even if I miss one or more of the sessions. No make-up sessions are provided. Switching group series is not permitted. I confirm and accept the dates below for the Friday Saturday Series by checking my choice of fee arrangements: Friday Saturday Series: August 13, September 17, October 15, November 12, December 10, 2022 & January 714, February 4, March 4, April 1, May 6, June 3, 20222023. Standard fee I agree to pay $450 for this consultation group series in full in advance by check. Or I authorize Dr. Leeds to charge my credit card below for six automatic payments of $80 each month the week of each session as listed above for a total of $480. Agency discount I request the 25% fee reduction available to clinicians employed in Community Mental Health and small nonprofit agencies. With this signed agreement I include a letter on agency letterhead confirming employment 30 hours or more per week. I agree to pay $337.50 for this consultation group series in full in advance, by check. Or I authorize Dr. Leeds to charge my credit card $60 per month for a total of $360. Credit Card Information Check one: ❏ MasterCard ❏ Visa ❏ Discover ❏ American Express Card number: Expires 3- or 4-digit Security Code Name on card: Signed: Date: Credit Card Billing Address: City: State: Zip: Country: Contact Information Mailing Address: City: State: Zip: Country: Phone: Fax: E-mail: Please print legibly. By signing below, I indicate my acceptance of this Group Consultation Agreement: Print Name: Signed: Date:
Appears in 1 contract
Limits of Service. It is expressly agreed that no supervision or employment relationship exists between Consultant and Consultee. Consultee – or Consultee’s legally mandated supervisor if any – remains solely responsible for services provided to Consultee’s clients. Consultant will provide information based on research, scholarly consensus, and Consultant’s experience for Consultee to consider. Consultee will rely on his or her own judgment in offering specific psychotherapy services to Consultee’s clients and will not state or imply he or she is following guidance from Consultant. EMDRIA Group Consultation hours only: This group is structured to provide only group consultation hours toward EMDRIA Certification. I will actively share my EMDR case work experience in each session. After the 6th group session, Dr. Leeds will provide documentation of group consultation hours for the time I spend in these sessions. Conflict resolution: A friendly atmosphere is advocated and fostered in the consultation process. If differences arise, both Dr. Leeds and I commit to resolving any issues in a professional and mutually beneficial manner, including, if necessary, bringing in a third party. Dr. Leeds and I each agree to abide by the code of ethics of the professional organization(s) to which we belong. Logistics: The consultation group will meet via Zoom for 6 sessions Friday Saturday Series: January February 5, March 12, April 9, May 7, February 4June 11, March 4, April 1, May 6, June 3July 2, 2022. Call times for the Friday series: Pacific: 9:00 – 11:00 AM; Mountain: 10:00 – 12:00 Noon; Central: 11:00 – 1:00 PM; Eastern: 12:00 – 2:00 PM The consultation group includes a maximum of eight members. I will be given in advance a series of Zoom meeting invitations that allow options for access by the Zoom application or telephone. I agree to securely share case files via a free account on Xxx.xxx. [Initial here] To keep consultation fees reasonable, I understand I will not be given an alternate session nor a refund if I am unable to attend one or more of the sessions for which I am registered. Confidentiality: [Initial here] As a member of this consultation group, I agree to notify clients and obtain their written consent to my seeking consultation without specifically identifying the name of my consultant. I will alter identifying information in any case material I present. I will treat as confidential all case material presented by others in this group. Work samples: When possible, I will provide written case summaries and/or near verbatim transcript of reprocessing sessions when presenting individual cases. A case summary form and near verbatim summary guide is available from Dr. Leeds website Resources page at: xxxxx://xxx.xxxxxxxxxxxxxxxx.xxx/resources [Initial here] I agree to pay the consultation group fee in full as described below even if I miss one or more of the sessions. No make-up sessions are provided. Switching group series is not permitted. I confirm and accept the dates below for the Friday Saturday Series by checking my choice of fee arrangements: Friday Saturday Series: January February 5, March 12, April 9, May 7, February 4June 11, March 4, April 1, May 6, June 3July 2, 2022. Standard fee I agree to pay $450 for this consultation group series in full in advance by check. Or I authorize Dr. Leeds to charge my credit card below for six automatic payments of $80 each month the week of each session as listed above for a total of $480. Agency discount I request the 25% fee reduction available to clinicians employed in Community Mental Health and small nonprofit agencies. With this signed agreement I include a letter on agency letterhead confirming employment 30 hours or more per week. I agree to pay $337.50 for this consultation group series in full in advance, by check. Or I authorize Dr. Leeds to charge my credit card $60 per month for a total of $360. Credit Card Information Check one: ❏ MasterCard ❏ Visa ❏ Discover ❏ American Express Card number: Expires 3- or 4-digit Security Code Name on card: Signed: Date: Credit Card Billing Address: City: State: Zip: Country: Contact Information Mailing Address: City: State: Zip: Country: Phone: Fax: E-mail: Please print legibly. By signing below, I indicate my acceptance of this Group Consultation Agreement: Print Name: Signed: Date:
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