Request appointment | Beneath the Surface Therapy

What is the main concern you would like help with?

One or two sentences, or a brief label such as “car accident” or “distressing hospital experience,” is enough. You may mention up to three priorities, but one is sufficient. Please do not provide graphic details or a full trauma history. “Not sure” or “prefer to discuss privately” is also acceptable.

How is this concern affecting your day-to-day life now?

A brief answer is enough: sleep, unwanted reminders, anxiety, avoidance, work, relationships, or another effect. You do not need to retell the event.

Which description best fits what you would like help with?

One specific distressing event or memory. A few specific events or memories. Repeated or childhood experiences and patterns that feel connected. A mix of a specific event and longer-standing concerns. I know what is bothering me, but I am not sure what memories are connected.

Which best describes your previous experience with trauma-focused treatment?

EMDR, but no other trauma-focused treatment. Another trauma-focused treatment, but not EMDR. Both EMDR and another trauma-focused treatment. No previous trauma-focused treatment. I am unsure or would prefer to discuss this privately.

Are you currently receiving care from a mental health professional?

This may include a therapist or a mental health medication prescriber. Provider names and contact details are not needed here. This answer does not authorize contacting your provider.

Yes. No. I would prefer to discuss this privately.

In the past month, have you had thoughts of suicide, urges or actions to harm yourself, or difficulty keeping yourself safe?

This form is not monitored for immediate help. If you need support now, call or text 988 in the United States. If you are in immediate danger or experiencing a medical emergency, call 911. Do not wait for a consultation invitation to seek urgent support.

No. Yes. I am not sure, or I would prefer to discuss this privately.

Is there anything about your health, recent changes in care, or alcohol/substance use that may affect participating in an extended session?

Examples might include recent hospitalization or crisis treatment, neurological or vision concerns, significant fatigue, medication changes, or difficulty staying sober for a session. A brief answer is enough; you may discuss details privately. Do not change prescribed medication to participate.

Limited to 600 characters

Would you have a private place in California for a 3- or 5-hour telehealth appointment, with breaks, and time and support afterward? What accommodations or scheduling needs should we consider?

Mention any privacy, technology, accessibility, caregiving, sensory, or scheduling needs. Support can include your own grounding routines, trusted people, or an existing clinician. You may say that you need help planning these arrangements. You do not need to choose a session length on your own.

Limited to 600 characters

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