New Patient Inquiry

EMDR Counseling & Consultation

Rachel Totten EMDRIA Certifed Consultant and Therapist
Name*

First NameLast Name
Contact Number:*
E-mail*
example@example.com
Note: SMS messages are not encrypted or secure. Texting is optional and only used for scheduling or logistical coordination. No clinical or confidential content will be shared via SMS. Message and data rates will apply. Message frequency varies. For help with text messaging reply HELP. You may reply STOP at any time to opt out. View our Privacy Policy at www.EMDRCounselingandConsultation.com/Privacy_Policy
I consent to receive SMS text messages for the following reasons (select all that apply):*

I am a therapy client and consent to receive SMS for scheduling or rescheduling sessions.I am attending a training with EMDR Counseling and Consultation and consent to receive SMS for time-sensitive Zoom access or logistical updates.I do not opt into SMS text messages
Please let me know the best way to follow up—email, phone, text or zoom?*

EmailPhoneTextZoom Meeting
Important Things to Note

EMDR Counseling and Consultation:
- Utilizes EMDR Psyhotherapy as the primary therapeutic model. EMDR Psychotherapy may or not contain the use of bilateral stimulation. This therapy approach relies of colloboration and connection between the client and the therapist working towards mutual agreed upon goals.
- Services are available in person (in Vermont) or online in the states where the provider is licensed, based on what best supports client needs.
- Is an out-of-network (OON) provider and does not contract with health insurance companies. Payment is due at the time of service. I may request a superbill or use courtesy billing through Reimbursify to submit claims for possible reimbursement from my health insurance carrier.
- Is not an inpatient, residential treatment center or urgent response service.
I have read and understand "Important Things to Note"*

Yes
Please let us know the type of EMDR support you're interested in.*

IndividualCouplesFamilyIntensiveUnsure
Please share a brief snapshot of where you are in your life right now, and what’s prompting you to consider therapy at this time.*
Would you like to stay connected? *
How did you come across our practice? Were you referred by someone, or did you find us online or elsewhere?*
Disclaimer:
This form is not HIPAA-compliant and is intended for general inquiries only. Please do not submit sensitive personal or health information. Submitting this form does not establish a therapist-client relationship.
Should be Empty:

EMDR Counseling & Consultation