Name *

First Name

Last Name

Phone *

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Individual Therapy Only *

I am fully aware The Team only provides individual therapy & EMDR Intensives

Yes, I am aware individual therapy & EMDR Intensives are the only services available

We can only provide these services to individuals in the state of California. Are you a resident of the state of California or visiting the state of California for an EMDR Intensive? *

I am a resident of California

I am visiting California to complete my EMDR Intensive

We only provide therapy to adults 18 years or older. By checking this box, you agree that you are 18 years or older. *

Yes, I am 18 years of age or older

By checking this box, I agree to receive electronic communication regarding future services. *

Yes, I agree