MQ EMDR Intensive Form
Please fill out the form below, and our office will reach out to you.
Insurance, Cost & Payment Information
Intensives: Not covered by insurance. You may be able to submit out-of-network claims for potential reimbursement based on your insurance benefits.
Payment: Must be completed before scheduling is confirmed. Payment options include credit card, Afterpay, and Klarna.
Cost for a 3-Hour EMDR Intensive Session:
3-Hour Intensive Session (includes 1-hour follow-up one month later): $1,997
Additional Follow-Up Sessions: $200/hr
Refund Policy: No refunds. Only 1 reschedules permitted.
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Email *
Name *
Date of birth *
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Physical Address (Please include City and State) *
Phone Number *
Preferred method of contact *
How did you hear about Mindset Quality? *
Are you currently in individual therapy? *
If in therapy,  Have you been cleared by your primary therapist or healthcare provider for intensive therapy sessions? *
If you answered yes to the previous question, please list all diagnoses and your therapist's name and number. (Write N/A if not applicable) *
EMDR Intensives are only offered Thursday- Sunday (Depending on availability).

Will this work with your schedule?
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Why do you think an EMDR intensive is the right option for you? *
Are you currently experiencing any severe mental health crises (e.g., psychosis, severe depression with suicidal ideation)? *
Do you have any unmanaged medical conditions that could interfere with your therapy sessions? *
Do you have any untreated substance abuse issues? *
Anything else we should know? *
By checking the box below you understand due to circumstances such as limited availability and/or the reasons in which you are seeking services for, that this form is not a guarantee of services. *
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