EMDR Intake Assessment
Phase 1: History & Treatment Planning
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Client: ________________
1 Client Information
2 Risk Assessment Critical
3 Goals, Strengths & Coping Skills
4 Trauma History
5 Triggers
6 Attachment Style (ASQ-SF)
7 Clinical, Medical & Special Considerations
8 Clinical Assessments
UCLA PTSD Reaction Index:
Dissociation Screening:
Affect Tolerance:
Avoidance Types:
Trauma Phobias:
9 Treatment Plan (Three-Pronged)
| Past Trauma Memories | Age | Present Symptoms | Triggers | Future |
|---|---|---|---|---|
Process earliest memory (touchstone) first, then worst event, then remaining targets chronologically.
EMDR Intake Assessment
Additional Notes
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Client: ________________