Clone of The PDA Mirror — Professional Interest Form

The PDA Mirror Professional Interest Form

Share your details and background so Liz Emen can confirm next steps.
For full program details, please visit emencounseling.com/demand-aware-practice
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
License Type and Credentials (e.g., LCSW, LMHC, LPC, PhD)
State(s) of Licensure
Name of Practice, Organization, or Employer
Current Work Setting

Other
City and State Where You Practice
Years in Practice
Preferred Scheduling
Scheduling Constraints or Notes
Anything we should know about your availability?
What is bringing you to The PDA Mirror right now?
How familiar are you with PDA (Pathological Demand Avoidance / Pervasive Drive for Autonomy)?
Which enrollment option interests you?
How did you hear about The PDA Mirror?

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, will follow up directly to confirm fit and next steps.
Have questions before or after filling this out? Reach Liz Emen, LCPC, LPC, LMHC, directly at emencounseling.com/contact
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The PDA Mirror Professional Interest Form