Clinical reference only. This content is intended for trained clinicians and does not replace formal EMDR training or supervision. See our family guide.
EMDR Intake Assessment
Phase 1: History & Treatment Planning
Page 1 of 2
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
Page 2 of 2
Client: ________________
Session Notes
Additional Trauma History / Target Sequence
Safety Plan Notes
Treatment Plan Updates
Disclaimer: This material is compiled from published clinical protocols and peer-reviewed sources. It is intended as a reference for trained clinicians only and does not replace formal EMDR training, supervision, or clinical judgment. Not for distribution to clients. Sources: Shapiro (2018), EMDRIA Guidelines, WHO (2013), APA (2017).