EMDR Intensive Questionnaire If you think EMDR Intensives is right for you, please fill out the form below. Name * First Name Last Name Email * Phone * (###) ### #### Are you looking for telehealth or in-person sessions (both are provided): * Telehealth In-Person If you are considering telehealth intensives, which state are you located in * I can only provide Intensives for residents of these states TX NV FL SD WY Do you understand what EMDR is and the difference between EMDR and EMDR intensives? * Yes No What do you want to address with EMDR? What is your goal? * Can you tie the issue(s) that you like to work on to event(s) in your life? Possibly even going back much further than most recently? * Yes No I'm not sure Are we working on one issue or multiple connected issues that affect your life? * Have you ever been in therapy before? * Yes No Do you have a current therapist? * Yes No Have you ever been hospitalized for psychiatric reasons? * Yes No Do you have any current thoughts of self-harm, self-harm behaviors or thoughts of suicide/homicide? * Yes No Sometimes Are you currently struggling with alcohol or drug abuse and actively using? * Yes No Are you taking any psychiatric medications? If yes, are you taking any benzodiazepine? If yes, how often? * Have you ever been diagnosed with Disassociate Identify Disorder, Dissociative Disorder, Schizophrenia, or a Personality Disorder? If yes, please identify: * Do you often space out or daydream? * Never A little bit Moderately Quite a bit A lot Do you feel like you have to act around others to fit into what you think is expected of you? * Never A little bit Moderately Quite a bit A lot Do you ever get angry easily which may lead to yelling or even physical altercations? * Yes No When you are stressed out, do you have the capacity to use coping and calming techniques to help to relax? If yes, please list what works for you. If no, do you have the capacity to learn coping and calming techniques and use them as directed? * Do you easily feel overwhelmed or get overstimulated? * Yes No Do you have the capacity to stay focused over a long period of time? * Yes No Do you understand the fee structure and are the fees within your range? * Yes No Thanks for submitting the EMDR Intensive questionnaire. The therapist will contact you at her earliest convenience
