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First EMDR Consultation
Please fill out the information below for your first appointment so I will have the information I need to fill out the documentation of your consultation hours.
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Today's Date
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Name:
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Your answer
Email Address:
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Your answer
Street Address
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Your answer
City/State/Zip Code
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Your answer
Best Phone Number to Reach you at:
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Your answer
Is this a:
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Cell Phone
Home Phone
Work Phone
Work Phone:
Your answer
What state are you licensed in?
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Your answer
What are you licensed as? (Mental Health Counselor, Psychologist, RN, etc.)
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Your answer
License #:
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Your answer
I am seeking EMDR Consultation for:
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Post Weekend 1 for the Basic Training
Post Weekend 2 for the Basic Training
EMDRIA Certification
Ongoing EMDR Skill Development
Who did you take, or are you taking your EMDR Basic Training from?
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EMDR Institute
EMDR HAP
Other:
Who was your trainer?
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Your answer
Dates of your training:
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Your answer
In which Time Zone was your Training?
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Your answer
Was your training Virtual or in person?
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Virtual
In Person
If in person, what location?
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Your answer
If you are seeking EMDRIA Certification (advanced certification after you have completed the EMDR Basic Training) make sure you have set up a time for us to go over the contract and created a plan for your certification process.
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