EMDR Client Intake Form

EMDR Client Intake Form
Please complete this form to help us understand your background and needs for EMDR therapy.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your primary reason for seeking EMDR therapy?
Have you previously received any form of therapy or counseling?
Briefly describe any traumatic experiences or significant life events you wish to address (optional)
Are you currently experiencing any of the following? (Select all that apply)
Other
Are you currently taking any medications? If yes, please list them.
Signature (Please sign below to confirm your consent)
Powered by Jotform SignClear
Should be Empty: