via|emdr - Intake Form

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Date of birth* This field is required.

Date

4

Email* This field is required.

example@example.com

5

Feel free to be brief: Why are you seeking counseling?

6

Are you military, former military, first responder, fire fighter, or a police officer?* This field is required.

YESNO

7

Do you have a preference on the provider you would like to see?* This field is required.

8

Are you currently being treated for mental health concerns at any other facility?* This field is required.

YESNO

9

Have received treatment for mental health concerns in the past?* This field is required.

YESNO

10

Do you currently have a primary care physician to help you with your medication concerns?* This field is required.

YESNO

11

Have you ever been diagnosed with any of the following; ADHD, Intellectual Disability, Learning Disorder or Autism?* This field is required.

YESNO

12

Do you require someone to assist you with basic daily functions, such as showering, getting dressed, feeding yourself or maintaining residency?* This field is required.

YESNO

13

Are you currently experiencing trouble with homelessness?* This field is required.

YESNO

14

Do you have a history of arrests, incarcerations or hospitalizations in the last 5 years?* This field is required.

YESNO

15

Are you currently involved in any court proceeding of any kind, probation, court ordered supervision, child custody, CPS, or divorce?* This field is required.

YESNO

16

Do you have a court case of any kind pending?* This field is required.

YESNO

17

Are you currently using illegal drugs or other substances?* This field is required.

YESNO

18

Are you currently using Alcohol or Marijuana frequently?* This field is required.

YESNO

19

Are you currently a victim of domestic Violence or Abuse?* This field is required.

YESNO

20

Do you have health insurance that you want us to bill? Unfortunately, we are unable to accept Molina at this time* This field is required.

YESNO

21

What is your Insurance Carrier/Provider?

22

When is your General Availability?

23

In person appointments or Virtual

In Person

Virtual

Either works

24

Would you be interested in scheduling an EMDR Intensive?

25

How did you hear about VIA-emdr?