The PDA Mirror Professional Interest Form
Emen Counseling Services, LLC - Demand Aware Practice
For full program details, please visit
emencounseling.com/demand-aware-practice
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Practice, Organization, or Employer
*
Please indicate your professional therapy identification (Social Worker, Counselor, Marriage & Family Therapist, etc)
*
License Type and Credentials (e.g., LCSW, LMHC, LPC, PhD)
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State(s) of Licensure
*
Current Work/Practice Setting
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Community Mental Health
Private Practice
Hospital or Medical Setting
Agency or Nonprofit
School-Based
Multiple Settings
Other
Other (please indicate your current work/practice setting)
Years of Licensed Therapy Practice
*
1-3 years
4-7 years
8-15 years
16+ years
Preferred Scheduling
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Weekday Daytime
Weekday Evening
Saturday Morning
Saturday Afternoon
Flexible / No Preference
Other
What is bringing you to The PDA Mirror right now?
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Scheduling Constraints or Notes
Anything we should know about your availability?
How familiar are you with PDA (Pathological Demand Avoidance / Pervasive Drive for Autonomy)?
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New to PDA
Some familiarity
Work with PDA clients regularly
Deep familiarity: it informs most of my practice.
Which enrollment option interests you?
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Starting 10/21: Founding Cohort rate · $375 (6 sessions + The Holding Space + 60-min 1:1 with Liz)
Not available immediately- Full rate · $540 (6 sessions + The Holding Space)
Try it first · $75 (Session 1 standalone, then decide)
Not sure yet — just want more information.
How did you hear about The PDA Mirror?
LinkedIn
Email outreach
Colleague referral
Emen Counseling Services website
Therapist listserv or group
Social Media/Facebook Group
Other
Any questions or anything you'd like Emen Counseling Services to know before connecting?
I understand that submitting this form does not constitute enrollment. Liz, at Emen Counseling Services, LLC will follow up directly to ordiscuss next steps.
*
I understand that submitting this form does not constitute enrollment. Liz will follow up directly to confirm fit and next steps.
Have questions before or after filling this out?
Book an intro call!
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