Blog

EMDR Consultation Form

Please fill out the form below.

Then click "Submit Form"when finished.

Consultation Form

Questions	Answers
((Fields marked with * are mandatory.))
Full Name *
Email Address *
1. Please list your main objective/s for today's consult (main areas of concern). *
2. Specific Questions regarding implementation of modality. *
3. Specific Questions regarding EMDR or Resourcing Technique: *
4. Other Questions or Concerns regarding Modality/Technique. *
5. At what stage of therapy are you in with this client? Stabilization or Trauma Processing? • Presenting Issue(s) and Why Now? *
6. Brief History (How long has client been in therapy? with you? Client's trauma history? attachment issues? Client"s goals for therapy? etc.) *
7. How well resourced is the client, i.e., did client present with sufficient internal and external supports? Yes No *
8. If NO, list what has been done to internally resource client, i.e., Which DBT skills have been taught and implemented; self soothing techniques taught and implemented? arousal reduction techniques taught and implemented? installation of resources using multi-sensory imagery with or without alternating bilateral stimulation, e.g. Container, Comfortable Place, Protector Figure, Nurturing Figure, adult Self: *
9. Questions regarding particular client(s):
To help prevent automated spam, please answer this question * Using only numbers, what is 10 plus 15?
Form provided by: FreeContactForm.com

Copyright © 2011 Integrative Trauma Treatment LLC User Agreement