Consultation Request Form
Welcome to Long Island EMDR!

At Long Island EMDR, we know the best predictor of your success in therapy is the connection you have with your therapist. It's ALL about finding someone who is a great fit for you! In this brief questionnaire, we are going to gather a little information about your current struggles, goals for therapy, and even your preferred days and times for appointments!
Demographic & Contact Information
Name of Client(s) First & Last *
Your answer
Birthday *
MM
/
DD
/
YYYY
Address *
Your answer
Name of Guardian (if applicable):
Your answer
Phone *
Your answer
Email *
Your answer
What is your preferred method of contact? *
***Please provide your partners Full Name, Email Address, and Phone Number you are interested in Couples Counseling.
Your answer
Relationship to Client (if applicable)
How did you hear about Long Island EMDR, formerly Suffolk Family Therapy? *
Name of individual who referred you:
Your answer
Getting Started in Therapy
We have an AMAZING group of Therapists who are excited to work with you! Using the information you provide, we help you find the best provider for YOU!

Please give a brief description of why you are seeking counseling at this time: *
Your answer
Please list your top 1-3 goals for therapy. What are you hoping to achieve from coming to therapy? *
Your answer
Which services are you interested in receiving? (Please check ALL that apply) *
Required
Appointment Availability
When there is more than one therapist we believe you will connect with we will schedule you with the Therapist who has the first available appointment time and/or the therapist who to matches your availability. The second greatest predictor of success is consistency. When you're able to meet with your therapists on a regular basis, progress happens. Therefore we are going to make sure you get off to a great start!

At Long Island EMDR, we understand life is hectic! It can be tough to dedicate time to something new. We want to help you fit therapy into your life. Your health and happiness is a priority. We do our part by assisting you to find a consistent day and time that works for you! We also know life isn't always so predictable! So if you can't meet the same day and time each week don't worry. We got your back too!

Please complete these questions below to help us determine the best days and times for you!
What are your preferred session times to see your therapist? (Please check ALL that apply) *
Required
What days would you prefer to see your therapist? (Please check ALL that apply) *
Required
Please indicate if you have a preference in therapist.  If the therapist(s) you choose are not available or the best fit for any reason, our office will recommend someone who would be a great fit! *
Required
Please share any questions or concerns you have about getting started. We are happy to answer any questions!
We understand how uncomfortable it is to reach out. It's common to have questions. Our office would be happy to speak with you about getting started.

Please share any questions, concerns or additional comments here!
Your answer
Please be aware, Long Island EMDR is in network with commercial plans that fall under Aetna & United Healthcare. All other insurances we are considered a private pay practice and an out-of-network provider. We charge $200 for 55 minute sessions. We collect payment at the time of service. We are happy to check your out of network benefits and submit claims on your behalf for possible reimbursement. Please let us know if you would like additional information about how you might access your out-of-network benefits! *
What is you Insurance Member ID number?
Your answer
What is your Insurance Group Number?
Your answer
Who is the policy holder?
What is the policy holder's name and date of birth?
Your answer
Thank you again for reaching out! We are excited to connect with you! Our office will reach out within 1-2 business days.
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