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EMDR Intensive Form
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Name
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Date of Birth
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Physical Address (Please include City and State)
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Phone Number
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Email
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Preferred method of contact
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Phone
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Are you currently in individual therapy?
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If you answered yes to the previous question, please list all diagnoses and your therapist's name and number.
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How did you hear about us?
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EMDR Intensives are only offered Friday afternoons. Will this work with your schedule?
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What is your understanding of EMDR and why do you think an EMDR intensive is the right option for you?
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Anything else we should know?
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By checking the box below you understand due to circumstances such as limited availability and/or the reasons in which you are seeking services for, that this form is not a guarantee of services.
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