Let’s Connect

Client Name *

First Name

Last Name

Phone *

(###)

###

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Is there a particular therapist you are interested in working with? *

Each therapist in our group practice has their own set fee based on their training and years of practice. Please read their bio to help determine who may be a good fit for you.

Lauren Petka, LPC Associate

Brittany Fellwock, LPC

Please match me with an available therapist.

Are you located in Texas? *

Yes

No

How did you hear about EMDR Therapy Austin? *

Internet search

Therapist referral

Doctor/prescriber referral

Client referral

Facebook

Instagram

Other

Safety and privacy disclaimer: You and your safety are important to us. If you are in immediate danger, please call 911 or go to an emergency room at the nearest hospital. 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: All consultations will be provided over the phone and all appointments will be offered via a secure and confidential televideo platform or via phone. *

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