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New Client Inquiry Form
Thank you for you interest in Philly EMDR Intensives!
In order to help you most effectively I'll need some information about you, financing your intensive, and your scheduling preferences.
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First & Last Name (ie: Jane Doe, Jack Loop-Yarn)
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First Name
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Last Name
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Email
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Phone Number
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What do you do for a living?
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How did you hear about Philly EMDR/Tina Kocol?
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Please share briefly about why you are looking to do an EMDR intensive.
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In what ways is your life limited by the trauma and/or stress you've experienced? (Consider your past, present, future)
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What triggers you?
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Please list 2-3 negative beliefs that commonly show up in your life? (i.e. I'm not good enough; I'm never safe; I'm broken; I never do anything right; I'm unlovable; etc.)
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What outcomes or changes would you like to have in your life after doing an EMDR intensive?
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Do you have any additional information that you'd like to share with me before your good-fit call?
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