Name *

First Name

Last Name

Phone *

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Status *

I am a Veteran (all discharge types)

I am currently serving in the military

Spouse

Health Insurance *

I have VA Health Benefits

I do not have insurance

I have Health Insurance

Next Step *

I would like to start seeing an EMDR Therapists

I would like to learn more about EMDR

I would like to schedule an informational appointment to learn more about EMDR and the process.

Therapy Preference *

I prefer in person EMDR Therapy

I prefer Telehealth EMDR Therapy

I have no preference between in person or Telehealth EMDR Therapy

Contact Preferences *

How would you prefer VRP to Contact you?

Email

Phone

Name *

First Name

Last Name

Phone

(###)

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Name *

First Name

Last Name

Phone

(###)

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