Referral Form
Trauma Transformed
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
What do you hope EMDR counselling will help you with?
*
Are you a Health Care Professional Looking for help with a critical incident or vicarious trauma?
*
Yes
No
Are you a first responder looking for counselling or EMDR to help with PTSD symptoms?
*
Yes
No
I am being referred by HSO
Are you a veteran looking for counselling for PTSD?
*
Yes
No
Are you looking for EMDR to help with intrusive childhood traumatic memories?Note a high ACE score requires a 4 to 6 month commitment of EMDR weekly or biweekly sessions
*
Yes
No
Are you being referred by the CF?
*
Yes
No
Are you wanting EMDR for a critical incident?Critical incident such as sexual assault, victim of crime, accidents
*
Yes
No
Have you recently been hospitalized for depression, or psychosis?
*
Yes
No
Are you currently using substances or alcohol to cope with PTSD or other symptoms?
*
Yes
No
Have you already seen several counsellors with no relief?
*
Yes
No
Are you willing to take a break from your counsellor while working with me?
*
Yes
No
Have you been diagnosed with clinical depression or major depressive disorder?
*
Yes
No
Have you ever been hospitalized for attempting to kill yourself?
*
Yes
No
It was a long time ago
Are you a CVAP client with an approved claim?
*
Yes
No
Are you an EMDR student in training?
*
Yes
No
Are you a practicing EMDR Therapist
*
Yes
No
Are you currently not employed and on disability benefits
*
Yes
No
Have you been diagnosed with DID?
*
Yes
No
How did you hear about us?
*
Google Ad?
Professional
Instagram
Popped up on an internet search
CounsellingBC roster
Psychology Today
Canadian EMDR
EMDRIA
Other
Please verify that you are human
*
Submit
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