EMDR Intensives Questionnaire

The screening questions below will help me determine if an EMDR Intensive may be a good fit for you. Answering “yes” to any question does not prevent you from being a candidate but it does help me be prepared to ask the right questions and provide meaningful supports. Your answers to these questions will not be shared with anyone.

First name

Email

Are you able to come to Northern Colorado (Fort Collins or Denver) in-person for your intensive? This may involve costs such as travel and booking one night to several nights at a hotel or AirBnb.

Yes

No

No, I want my intensive to be online (only available for 3-hour sessions)

Have you been hospitalized for psychiatric reasons within the past 12 months?

Yes

No

Do you currently have any thoughts of self harm, self harm behaviors, thoughts of suicide/homicide? Check all that apply.

Are you currently struggling with alcohol or drug use?

Yes

No

Other

Have you ever been in therapy before?

Yes

No

Do you have a current therapist?

Yes

No

Are you willing to have me communicate with your current therapist to discuss goals, progress, and incorporating lessons from our intensive into your sessions together?

Yes

No

I have no therapist

Yes, But... (explain what you wish discussed versus withheld in box at bottom of form)

Please describe your experience in past/current therapy. Have you found it beneficial? What have you learned about yourself throughout your therapy experience?

Have you ever done EMDR before?

Yes

No

If you have participated in EMDR therapy previously, what did you find helpful about it? How did it go?

Is the event you want to address with EMDR a single incident or an ongoing issue? Choose all that apply.

Single incident (example - a car accident, an assault, a medical trauma)

Ongoing issue (example - abusive relationship with multiple incidents)

More complex (example - childhood traumas, attachment trauma with primary caretaker, things that have been present for a long time)

Other

What makes the EMDR Intensive seem like a good fit for your needs? What do you hope to gain by completing an EMDR intensive?

Add any notes here to clarify your above answers if needed!