Name *

First Name

Last Name

Phone number for call and text:

(###)

###

####

Problem(s) of Concern: *

Depression

Anxiety and/or Panic

PTSD/Trauma

Dissociation

Other

Not related to becoming a client

Which service are you interested in? *

EMDR Intensive(s) (3+hr sessions/not covered by insurance)

Therapy Retreat

Professional Training/Consultation

Refer a client

Weekly Therapy

Other

Is this a Workman's Comp case? *

Yes

No

Would you like to receive text communications for scheduling purposes? *

For scheduling/brief administrative contact as needed in between sessions

Yes

No

Paying for Services *

Are you hoping to use insurance benefits?

Self-pay

Blue Cross and Blue Shield

United

Out of Network

Preferred Venue for Therapy *

Where are you hoping to receive services?

Telehealth/Online

Retreat at Shoofly Farm in Auburn, AL

Allen Therapy Office in Opelika, AL

In-person at another venue