Adult EMDR Appointment Request Form
Let us know how we can help you!
What state are you currently located in?
*
California
Florida
Idaho
Nevada
Tennessee
Texas
Other
How often are you looking for EMDR Therapy?
Weekly Appointments
Biweekly Appointments
EMDR Intensives
I'm not sure, I'd like to discuss it
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What is your gender?
Please Select
Male
Female
What is your age range?
Please Select
18-29
30's
40's
50's
60's
65+
Scale of 1-5, how hard has this been for you?
Please Select
1 (not too hard)
2
3
4
5 (it's been really hard)
What are you struggling with?
*
Anxiety
Depression
Feeling Lost
Stress
My Relationship
Substance Use
Trauma
Other
Where are you looking to attend sessions?
*
In Person: Vacaville, CA
In Person: Roseville, CA
In Person: Gold River, CA
Online
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Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Availability
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times
*
Mornings (8 AM - 12 PM)
Afternoons (12 PM - 4 PM)
Evenings (5 PM- 8 PM)
How did you hear about Freedom Counseling Group?
Internet Search/Google
Recommended by a friend or family member
Recommended by a doctor
Other
Is there anything else we forgot to ask?
Let us know if there is any other information that would be helpful for us to be aware of as we match you. Please note we will need full names and email addresses for each potential participant if you are looking to participate in family or couples counseling.
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