Application for EMDR Intensive

Thank you for your interest in the 2-Day EMDR Trauma Intensive.

This accelerated format is designed for individuals who are emotionally stable, motivated for deep trauma work, and ready to engage in a focused, structured healing experience.

Because this is a specialized service, all applicants complete this form to determine clinical appropriateness. Submitting this application does not guarantee acceptance. If it appears to be a good fit, you will be invited to schedule a consultation call.

First and Last Name:

Trauma History & Goals

In general terms, what experiences would you like to focus on during the intensive? (You do not need to share explicit details here.)

How long have these experiences been impacting your life?

Have you previously participated in therapy?

Yes, in the past.

Yes, currently in therapy.

If yes to above, how long were/have you been in therapy for?

If yes, what felt helpful? What still feels unresolved?

What is motivating you to pursue an intensive format rather than weekly therapy?

What would feel like a meaningful outcome after two days of focused trauma work?

Clinical Stability Screening

Are you currently experiencing thoughts of harming yourself?

Yes, passive thoughts only. (No plan or intention of harming self)

Yes, active thoughts with plans and/or intention.

No, I am not experiencing any thoughts of harming myself.

Have you engaged in self-harm behaviors within the past 3 months?

Yes

Are you currently struggling with substance use that feels out of control?

Yes

Have you ever been hospitalized for psychiatric reasons?

Yes

If yes, briefly describe when, for how long, and why:

Are you currently taking any psychiatric medication?

Yes

If yes, how long have you been stable on your current dosage?

Are you currently in an unsafe or abusive living situation?

Yes

Emotional Regulation & Dissociation

When you become emotionally triggered, what typically happens? (e.g., shut down, panic, anger, dissociate, intellectualize, etc.)

Are you generally able to calm yourself within a few hours after becoming emotionally activated?

Yes

Sometimes

Rarely

Do you experience dissociation? (Check any that apply)

Feeling detached from your body

Feeling unreal or foggy

Losing track of time

Not remembering parts of conversations

I do not exI do not experience dissociationperience dissociation

Other

Do you have a history of severe or complex dissociation (e.g., multiple distinct identity states)?

Yes

Unsure

Readiness & Support

Are you able to take two full consecutive days off work and minimize responsibilities for 72 hours afterward?

Yes

Do you have reliable childcare (if applicable)?

Yes

Not applicable

Do you have at least one supportive person available to you after the intensive if needed? (ie, therapist, friend, spouse, parent, family member)

Yes

Are you willing to participate in two follow-up integration sessions after the intensive?

Yes

On a scale of 1–10, how ready do you feel to process difficult memories if it could lead to long-term relief?

Financial & Commitment Acknowledgment

The investment for the 2-Day EMDR Trauma Intensive is currently $3,500 and includes a preparation session, two full intensive days, and two integration sessions. Are you prepared to make this financial commitment?

Yes

I would need a payment plan

Unsure

Is there anything else you would like me to know before determining whether this is a good fit?

Are you located in one of the following states: Idaho, Washington, Connecticut, or New Jersey or willing to travel to Idaho for this intensive treatment?

Yes

Thank you!

Please provide contact information for how you would like to be informed about next steps (email, phone (call and/or text):

Application for EMDR Intensive

Thank you for your interest in the 2-Day EMDR Trauma Intensive.

This accelerated format is designed for individuals who are emotionally stable, motivated for deep trauma work, and ready to engage in a focused, structured healing experience.

First and Last Name:

Trauma History & Goals

In general terms, what experiences would you like to focus on during the intensive? (You do not need to share explicit details here.)

How long have these experiences been impacting your life?

Have you previously participated in therapy?

Yes, in the past.

Yes, currently in therapy.

If yes to above, how long were/have you been in therapy for?

If yes, what felt helpful? What still feels unresolved?

What is motivating you to pursue an intensive format rather than weekly therapy?

What would feel like a meaningful outcome after two days of focused trauma work?

Clinical Stability Screening

Are you currently experiencing thoughts of harming yourself?

Yes, passive thoughts only. (No plan or intention of harming self)

Yes, active thoughts with plans and/or intention.

No, I am not experiencing any thoughts of harming myself.

Have you engaged in self-harm behaviors within the past 3 months?

Yes

Are you currently struggling with substance use that feels out of control?

Yes

Have you ever been hospitalized for psychiatric reasons?

Yes

If yes, briefly describe when, for how long, and why:

Are you currently taking any psychiatric medication?

Yes

If yes, how long have you been stable on your current dosage?

Are you currently in an unsafe or abusive living situation?

Yes

Emotional Regulation & Dissociation

When you become emotionally triggered, what typically happens? (e.g., shut down, panic, anger, dissociate, intellectualize, etc.)

Are you generally able to calm yourself within a few hours after becoming emotionally activated?

Yes

Sometimes

Rarely

Do you experience dissociation? (Check any that apply)

Feeling detached from your body

Feeling unreal or foggy

Losing track of time

Not remembering parts of conversations

I do not exI do not experience dissociationperience dissociation

Other

Do you have a history of severe or complex dissociation (e.g., multiple distinct identity states)?

Yes

Unsure

Readiness & Support

Are you able to take two full consecutive days off work and minimize responsibilities for 72 hours afterward?

Yes

Do you have reliable childcare (if applicable)?

Yes

Not applicable

Do you have at least one supportive person available to you after the intensive if needed? (ie, therapist, friend, spouse, parent, family member)

Yes

Are you willing to participate in two follow-up integration sessions after the intensive?

Yes

On a scale of 1–10, how ready do you feel to process difficult memories if it could lead to long-term relief?

Financial & Commitment Acknowledgment

Yes

I would need a payment plan

Unsure

Is there anything else you would like me to know before determining whether this is a good fit?

Are you located in one of the following states: Idaho, Washington, Connecticut, or New Jersey or willing to travel to Idaho for this intensive treatment?

Yes

Please provide contact information for how you would like to be informed about next steps (email, phone (call and/or text):