EMDR/Trauma Intensive Inquiry Form (insurance NOT accepted)

Please complete the form below

Name *

First Name

Last Name

Email *

Phone *

Please enter a number where you can freely be reached

Are you 18 years old or older? *

YES

NO

If No, please enter the name and contact information for your parent/guardian.

Do you have traumatic memories or maladaptive patterns to address? *

Yes

No

Unsure

Interested in

Weekend intensives

1/2 day session

3/4 day session

Full day session

By submitting this form you are agreeing to being contacted by a staff member of NyLu Therapeutic Solutions. Submitting this form does not sign you up for an EMDR intensive session. Do you agree to being contacted to further discuss participation in this intensive session? *

YES

NO

Please indicate the best way to contact you. *

Thank you for your interest in doing an EMDR Intensive session . Please use the following link to schedule a video consult:

meetmonarch.com/therapist/tamia-pleasants-lcpc-silver-spring-md

Best…

POWERED BY SQUARESPACE