Therapy Request Form

EMDR Therapy

Please note that I am only accepting clients for EMDR Therapy.

Question Title

* 1. What State do you need services in?

Question Title

* 2. Name

Question Title

* 3. Phone number:

Question Title

* 4. Email address:

Question Title

* 5. Provide a summary of your challenges and therapeutic goals.

Question Title

* 6. Would you be using insurance?

Yes (Please note that I accept insurance for only New York residence. Also insurance doesn't cover EMDR Intensive)

No

Question Title

* 7. Are you interested in weekly EMDR or EMDR Intensive Therapy

Weekly EMDR

EMDR Intensive

Not Sure