Kirkland EMDR Counseling Waitlist

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Hello and thank you for reaching to Kirkland EMDR Counseling. Engaging in therapy can be a big investment towards yourself and we believe it's important to find the right fit that can serve your current needs and goals in this process. Please complete this form in order to be placed on our waitlist. Once we have a spot open, our office assistant will reach out and you'll have a 48 hour window to respond. If you have any questions or concerns please reach out to our office assistant, Erica at welcome@kirklandemdr.com

By providing your email address you are consenting to email communication with us.

Please note: We are only able to serve clients living in Washington State through Telehealth.

*If you are currently in crisis please go to your nearest emergency room OR call/text the Suicide & Crisis Lifeline at 988*

Email *

First and Last Name *

Preferred name if different than above:

Pronouns *

Phone Number *

Documents are available in English and Spanish. Please indicate which language you would like your forms in:

English

Spanish

Clear selection

Are you interested in *

EMDR Individual Therapy

Individual Therapy (Other than EMDR)

Do you have health insurance you'd like to use? If so, which insurance company is it?

We are in network with: Premera, LifeWise, and most Anthem BCBS plans. We are happy to bill Out of Network for other plans.

If you are choosing to use insurance, is this your primary or secondary insurance?

How important is it for you to see a therapist that can take your insurance? *

I will only see a therapist who is in Network

I will see a therapist that is Out of Network

I will see a therapist who cannot bill insurance/ I'll pay entirely out of pocket

Other:

Required

How did you hear about us?

Friend

Referral from a Doctor or Therapist

Through my Insurance

Internet Search

TherapyDen

Inclusive Therapists Network

Other:

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If you were referred by a doctor or other professional please let us know who referred us:

Briefly explain why you are seeking therapy at this time: *

Do you know anyone who has been/is in treatment at Kirkland EMDR Counseling? If so, who? *

Are there any particular times/days that work best for you?

Additional Telehealth questionnaire

All appointments are telehealth video counseling. Please note you must be physically located in the state of Washington for Teletherapy sessions.

Do you have a computer, tablet or smartphone for a video call? *

I have a smart phone or tablet in order to join video sessions

I have a computer with a camera and audio and I will join the video sessions

Other:

Required

Do you have a safe and private location where you could have a video session? *

Yes

Is there anything else you'd like us to know?

By clicking the box below, you acknowledge that you consent to receiving email communication with us to follow up with you. Completing this questionnaire is not a guarantee of services. *

Yes, I understand and agree

Required

THANK YOU for reaching out and taking the time to fill out this form!

We're looking forward to getting to know you and we will contact you when we have an opening for you.

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