Interest in Prolonged Exposure Therapy

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Please fill out this form if you are interested in working with Dr. Jacob Glickman (pronouns: he/him) on healing from a past traumatic experience. There are immediate openings, and all sessions are free.

What is your name? *

What are your pronouns?

Please check all that apply.

she/her

he/him

they/them

ze/hir

none (just my name)

Other:

What is your email address?

Please feel free to leave blank or specify the hours during which you can be reached.

What is your phone number?

Please feel free to leave blank or specify the hours during which you can be reached.

Have you ever experienced, witnessed, or been repeatedly confronted with any of the following?

Please check all that apply.

Serious, life threatening illness (heart attack, etc.)

Physical assault (attacked with a weapon, severe injuries from a fight, held at gunpoint, etc.)

Sexual assault (rape, attempted rape, forced sexual act with a weapon, etc.)

Military combat or lived in a war zone

Child abuse (severe beatings, sexual acts with someone five years older than you, etc.)

Accident (serious injury or death from a car, at work, a house fire, etc.)

Natural disaster (severe hurricane, flood, earthquake, etc.)

Other:

Required

Prolonged exposure includes some work outside of session in order to help healing take place more than just one day out of the week. Would you rather have reading materials provided as a PDF or through an app? *

PDF copies

PE Coach app

Prolonged exposure includes listening to recordings of the sessions in order to help healing take place more than just one day out of the week. Are you okay with sessions being recorded? *

Recordings, like all therapy information, will be stored securely and kept confidential.

Yes, I understand that recordings are a part of the therapy.

No, I am not sure I am currently interested in prolonged exposure therapy.

Required

When are you typically available to meet for a session?

Please check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

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