Initial Client Inquiry Form

Name *

First Name

Last Name

Session type

In person

Telehealth

Either in person or telehealth

Availability

9am- 1pm (weekdays)

4pm-7pm (weekdays)

Type of therapy

Individual

Couple

EMDR Intensive

Couples Intensive

Phone / Email

(###)

###

####

Please respond via

Email

Phone

Either