Intensive Interest Form
Share your contact details, the intensive you’re interested in, and what you hope to be different after we meet.
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred way to contact you
Please Select
Phone
Email
Text message
Other
Goals and Context
Tell me a little about what's bringing you here
*
If our time together were helpful, what would you hope is different afterward?
*
Are there any upcoming dates, events, or transitions influencing your interest in an intensive?
Therapy History
Have you worked with a therapist before?
*
Yes
No
Have you previously experienced EMDR?
Yes
No
Session Preferences
Where would you prefer to meet?
*
Office
My home (if appropriate)
I'm not sure
Another meaningful location
Which length sounds like it might fit your needs?
*
2 hours
3 hours
4 hours
I'm not sure
Anything else you would like us to know?
Submit Inquiry
Should be Empty: