Praxis Thriving / Dissociation Therapy Austin

Name *

First Name

Last Name

Phone *

(###)

###

####

Do you prefer in-person or online appointments? *

In Person

Online

Reason(s) for Seeking Services *

Select all that apply

Chronic Pain / Chronic Health Conditions

Complex Trauma Recovery

Dissociation - DID/OSDD

Dissociation - Depersonalization/Derealization

EMDR

Narcissistic Abuse Recovery

Organized Abuse

Religious Abuse

Trauma Recovery

Other

Where are you located? *

I am only licensed and able to provide services to residents of Florida, New Mexico, Texas, and Wisconsin

Florida

New Mexico

Texas

Wisconsin

Other

Are you over the age of 18? *

I work with individual adults, 18 years and older

Yes

No

Are you currently working with a therapist and seeking EMDR to supplement your current treatment? *

Yes

No

How did you hear about Praxis Thriving / Dissociation Therapy Austin? *

Internet Search

Therapist Referral

Client Referral

Facebook

YouTube

Other

Disclaimer: Please be aware that this form will be submitted via email. The use of the internet or this form for communication does not establish the therapeutic relationship, and confidential information should not be sent through this form. *

I have read the disclaimer and acknowledge and agree to its contents.

Telehealth disclaimer: I understand that all consultations and appointments are offered via a secure and confidential video platform for your convenience. *

I only see clients online for EMDR and counseling. I do not have in-person appointments available.

I have read the Telehealth disclaimer and acknowledge and agree to its contents.