EMDR Suitability Reflection Questions for Clients and potential clients

This form is to help us both understand whether EMDR (Eye Movement Desensitisation and Reprocessing) could be a good fit for you right now. You’re welcome to write as much or as little as you’d like. You can use bullet points, short sentences, or just bring the form to session and we can talk it through together.

1. Current Difficulties

What has brought you to therapy at this time?

______________________________________________________________________

Are there particular emotions, body sensations, thoughts, or patterns you'd like to work on?

______________________________________________________________________

Do you ever feel “stuck” in the past, or like a memory still affects you in the present?

______________________________________________________________________

Do any particular body sensations, images, emotions or thoughts repeat during stressful times?

______________________________________________________________________

2. Life Experiences

Have you experienced any of the following? (Tick anything relevant or add your own.)

______________________________________________________________________

- Accidents or injuries- Medical procedures or hospital stays- Emotional neglect or lack of safety- Emotional, physical, or sexual abuse- Bullying or humiliation- Loss, grief, or abandonment- Feeling “stuck” in certain moments or memories- Other experiences: __________

______________________________________________________________________

Are there memories that feel frozen in time, or too overwhelming to think about?

______________________________________________________________________

Do any memories come with intense body sensations, emotions, or images?

______________________________________________________________________

3. Internal Processing & Sensory Experience

How do you tend to process emotions? (e.g. internally, through writing, talking, movement, needing time alone, etc.)

______________________________________________________________________

Are you sensitive to sensory input (e.g. bright lights, noise, textures, smells)? If yes, which kinds are most difficult or soothing?

______________________________________________________________________

What happens in your body when you're overwhelmed, anxious, or shut down?

______________________________________________________________________

Do you find it easy or difficult to stay connected to your body?

______________________________________________________________________

4. Coping and Regulation

What currently helps you feel calm, grounded, or emotionally steady?

______________________________________________________________________

Do you use any strategies when overwhelmed (e.g. breathing, stimming, music, sensory tools, movement)?

______________________________________________________________________

Would you be open to learning grounding or calming techniques before starting EMDR? (Yes / Maybe / Not right now)

______________________________________________________________________

Do you have any sensory items, movements, or routines that help regulate you?

______________________________________________________________________

5. Dissociation or Disconnection

Have you experienced any of the following?- Spacing out or losing track of time- Feeling emotionally numb or flat- Feeling outside of your body- Feeling like the world or people around you aren’t real- Feeling like you're not fully present in your own life- Going blank, freezing, or being unable to speak under stress

______________________________________________________________________

If yes, how often does this happen? (Occasionally / Often / Only in specific situations: __________)

______________________________________________________________________

6. Imagery and Visualisation

Can you imagine calming places, people, or images in your mind easily?

______________________________________________________________________

Would visualisation exercises feel calming or activating for you?

______________________________________________________________________

Would you prefer grounding through physical sensations (e.g. holding an object, movement, sound)?

______________________________________________________________________

Do metaphors, symbols, or stories tend to feel more comfortable than direct emotion work?

______________________________________________________________________

7. Parts of Self

Do you ever feel like there are different parts of you that want different things?

______________________________________________________________________

Do younger versions of you ever show up emotionally in adult situations?

______________________________________________________________________

If a part of you didn’t want to do EMDR, what might they be worried about?

______________________________________________________________________

8. Safety and Support

Do you feel safe enough in your current environment to begin processing deeper experiences?

______________________________________________________________________

Do you have people, pets, or routines that help you feel safe or cared for?

______________________________________________________________________

Is there anything about your home, relationships, or daily life that may affect your ability to rest or recover after therapy?

______________________________________________________________________

What helps you feel emotionally safe in relationships with others?

______________________________________________________________________

Is there anything you’d like me to avoid in how I speak or interact?

______________________________________________________________________

9. Mental and Physical Health

Have you ever been given a mental health diagnosis? Are you taking any medication?

______________________________________________________________________

Have you ever experienced psychosis, mania, suicidal thoughts, or self-harm?

______________________________________________________________________

Anything you'd like to share about your sleep, energy levels, physical health, or recent changes?

______________________________________________________________________

10. Thoughts About EMDR

Have you heard of EMDR before? What do you already know or feel about it?

______________________________________________________________________

Are there parts of the idea that feel unclear, exciting, or worrying?

______________________________________________________________________

How do you usually respond when difficult feelings or memories come up?

______________________________________________________________________

Would you be open to exploring memories in a structured and supported way if we build safety first?

______________________________________________________________________

Do you prefer to know what’s coming in sessions ahead of time, or more flexibility?

______________________________________________________________________

Would breaks, pauses, or short check-ins during processing be helpful for you? (Yes / Maybe / No)

______________________________________________________________________

11. Self-Assessment

Please tick what feels true for you right now:I feel ready to explore difficult memories or sensations [ ]I have ways to calm or ground myself after intense emotions [ ]I can stay present, at least some of the time, when I'm distressed [ ]I am open to learning regulation or grounding tools [ ]My current environment feels safe enough to begin deeper work [ ]I feel emotionally safe enough with my therapist to begin EMDR [ ]I feel able to say “no” or “pause” in sessions if something feels too much [ ]

______________________________________________________________________

12. Anything Else

Is there anything else you’d like me to know about:- Your communication style- What helps you feel seen or understood- What you need from me to feel safe in the room- What would help you feel ready for this kind of work

______________________________________________________________________