EMDR Intensives Request Form

EMDR Intensives Request Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date you would like to start:

MonthDayYear
Date
If there is anything you want the therapist to know ahead of time, please insert that information here:
I understand that EMDR Intensives consists of 3-4 hour sessions over the course of 3-4 days for a total of 12 hours of session time. These are not typically covered by insurance but may be payed for with a HSA or likewise account. The therapist will reach out to you directly to provide scheduling options and to send you an invoice for the EMDR Package.
Signature

Powered by Jotform SignClear
Should be Empty: