• Freedom Fighters Therapy VA Community Care Intake Packet

  • Welcome to Freedom Fighters Therapy LLC

    Thank you for choosing Freedom Fighters Therapy LLC for your VA Community Care mental health services.This secure intake packet is designed specifically for Veterans receiving care through the VA Community Care Network. It contains the required intake forms, consents, policies, assessments, authorizations, and releases needed to begin treatment with our practice.Please complete each section carefully and answer all questions honestly and accurately. Your appointment cannot be finalized until all required intake paperwork has been completed and submitted.We are honored to have the opportunity to serve you and appreciate your trust in our team.

  • Freedom Fighters Therapy LLC provides professional telehealth mental health counseling for Veterans through the VA Community Care Network.

    Our licensed clinicians provide services only while clients are physically located in a state where the treating clinician is licensed or otherwise authorized to practice.

    This intake packet is intended only for Veterans receiving authorized VA Community Care services through Freedom Fighters Therapy LLC.

    Submitting this intake does not guarantee an appointment. Your referral authorization and completed intake paperwork must be reviewed and approved by our office before services can be scheduled or confirmed.

  • Emergency Notice

  • Emergency Notice

    Freedom Fighters Therapy LLC is NOT an emergency service.

    If you are experiencing a medical emergency, mental health crisis,
    believe you may harm yourself or another person, or require immediate
    assistance:

    • Call 911
    • Call or Text 988
    • Go to the nearest Emergency Department

    Please do not use this intake form, email, voicemail,
    text message, or the client portal to request emergency assistance.

  • Are you currently experiencing thoughts of harming yourself?Single Choice*

  • Client Information

  • Please complete the following information exactly as it appears on your legal identification and insurance records (if applicable).

  • Date of Birth*
     - -
  • Biological Sex
  • Format: (000) 000-0000.
  • May we text you?*
  • May we leave a voicemail?
  • Format: (000) 000-0000.

  • Clinical Information

  • Please answer the following questions as completely and accurately as possible. These questions help your clinician prepare for your first appointment and develop the most appropriate treatment plan or coaching approach.

  • Have you previously received counseling, therapy, or life coaching?*
  • Do you currently have a Primary Care Provider (PCP)?*
  • Format: (000) 000-0000.
  • Have you ever been hospitalized for mental health or substance use treatment?*

  • Scheduling Preferences

  • Please tell us your scheduling preferences. While we cannot guarantee specific appointment times or providers, we will make every effort to accommodate your preferences.

  • Do you have a provider preference?*
  • Preferred Appointment Days*
  • Preferred Appointment Times*
  • Would you like to be placed on our cancellation list for an earlier appointment if one becomes available?*
  • How did you hear about Freedom Fighters Therapy?*

  • VA Community Care Agreement

  • Thank you for choosing Freedom Fighters Therapy LLC for your VA Community Care services.

    This agreement explains how your VA Community Care services are provided, how your records are shared with the Department of Veterans Affairs, your attendance responsibilities, and your rights as a client. Please read each section carefully before continuing.

  • VA Community Care Services

  • Freedom Fighters Therapy LLC provides behavioral health services for eligible Veterans through VA Community Care contracts.

    Veterans receiving VA-authorized services are not required to provide a credit card for VA-covered treatment.

  • Assessment and Outcome Testing Requirements

  • Veteran clients agree to complete required clinical assessments including the PHQ-9, GAD-7, and PTSD screening measures when clinically required and/or requested by VA Community Care.

    Testing may occur at intake and periodically during treatment as required by VA Community Care.

  • Communication Expectations

  • The practice may communicate through HIPAA-compliant text messaging, telephone, secure electronic platforms, and other approved methods of communication.

    Email may not always be the fastest method of communication. Clients are encouraged to respond promptly to telephone calls and text messages from the practice.

  • Medical Records

  • Active VA clients receiving ongoing authorized services are not charged a medical record preparation fee for routine VA-required records.

    Veterans who are discharged, inactive, or no longer receiving active services and later request copies of records may be charged a $75 medical record preparation fee when permitted by law.

  • Privacy and Confidentiality

  • Client information is protected in accordance with HIPAA and all applicable federal and state laws.

    Information will only be released with proper authorization or when required by law.

  • Consent to Treatment

  • I consent to participate in counseling services provided by Freedom Fighters Therapy LLC.

    I understand that treatment methods, potential benefits, risks, and alternatives will be discussed with my treating provider.

  • Intern and Trainee Disclosure

  • Freedom Fighters Therapy LLC may utilize interns, trainees, or supervised providers.

    Clients will be informed whenever services involve an intern or trainee and written consent will be obtained before services are provided by a trainee.

  • Technology and AI Documentation

  • Freedom Fighters Therapy LLC may use secure technology tools, including AI-assisted documentation support, to assist with administrative documentation and preparation of clinical notes.

    Clinical judgment and final documentation remain the responsibility of the treating provider.

  • Grievance Procedure

  • Clients may discuss concerns with their provider or contact Freedom Fighters Therapy LLC administration.

    Complaints will be reviewed respectfully and without retaliation.

  • Therapy Policies, Consents, and Client Rights

  • The following policies apply to all therapy clients receiving services through Freedom Fighters Therapy LLC. These policies explain your rights, our responsibilities, privacy practices, telehealth procedures, communication expectations, and informed consent for treatment.

    Please read each section carefully before continuing.

  • Consent to Treatment

  • I voluntarily consent to participate in behavioral health treatment provided by Freedom Fighters Therapy LLC.

    I understand the purpose of counseling is to improve emotional, behavioral, relational, and psychological well-being. My provider will discuss treatment options, potential benefits, possible risks, and alternatives throughout treatment.

    I understand no guarantees can be made regarding treatment outcomes.

  • HIPAA Notice of Privacy Practices

  • Freedom Fighters Therapy LLC is committed to protecting the privacy and confidentiality of your Protected Health Information (PHI).

    Your information will be used only for treatment, payment, healthcare operations, or as otherwise permitted or required by law.

    A complete Notice of Privacy Practices is available upon request.

  • Telehealth Consent

  • Most therapy services are provided through secure HIPAA-compliant telehealth platforms.

    You agree to participate in telehealth sessions from a private location whenever possible.

    You understand you must be physically located in a state where your assigned clinician is legally authorized to practice at the time of each session.

    You agree to provide your physical location at the beginning of each telehealth appointment.

    You agree to notify Freedom Fighters Therapy LLC if you will be located in a different state prior to your scheduled appointment.

     

  • Electronic Communication

  • Freedom Fighters Therapy LLC may communicate using secure telephone calls, text messaging, email, electronic forms, and approved client communication platforms for scheduling, reminders, billing, and administrative purposes.

    Electronic communication should never be used during emergencies.

    Text messages and email are intended for scheduling and administrative communication and should not be relied upon for urgent clinical concerns.

  • AI-Assisted Documentation

  • Freedom Fighters Therapy LLC may use secure technology tools, including AI-assisted documentation support, to improve documentation efficiency.

    Your treating clinician remains responsible for reviewing, editing, and approving all clinical documentation.

    AI tools are never used to replace professional clinical judgment.

  • Client Rights and Responsibilities

  • Freedom Fighters Therapy LLC may communicate using secure telephone calls, text messaging, email, electronic forms, and approved client communication platforms for scheduling, reminders, billing, and administrative purposes.

    Electronic communication should never be used during emergencies.

    Text messages and email are intended for scheduling and administrative communication and should not be relied upon for urgent clinical concerns.

  • Grievance Procedure

  • If you have concerns regarding your care, please discuss them with your provider or contact Freedom Fighters Therapy LLC administration.

    Every concern will be reviewed fairly and respectfully.

    Clients will never be retaliated against for filing a complaint.

    Receive information regarding fees, billing practices, and financial responsibilities.

  • Emergency Policy

  • Freedom Fighters Therapy LLC is not an emergency or crisis-response service.

    If you experience thoughts of harming yourself or another person, call 911, call or text 988, or go immediately to the nearest emergency department.

  • PHQ-9 Depression Questionnaire

  • Please answer the following questions based on how you have been feeling over the past two (2) weeks.

    Your responses help your provider better understand your current symptoms and monitor your progress throughout treatment.

  • Little interest or pleasure in doing things*
  • Feeling down, depressed, or hopeless*
  • Trouble falling or staying asleep, or sleeping too much*
  • Feeling tired or having little energy*
  • Poor appetite or overeating*
  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down*
  • Trouble concentrating on things, such as reading the newspaper or watching television*
  • Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual*
  • Thoughts that you would be better off dead or of hurting yourself in some way*
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

  • Generalized Anxiety Disorder 7 (GAD-7)

  • Over the last two (2) weeks, how often have you been bothered by the following problems?

    Please answer every question.

  • Feeling nervous, anxious, or on edge*
  • Not being able to stop or control worrying*
  • Worrying too much about different things*
  • Trouble relaxing*
  • Being so restless that it is hard to sit still*
  • Becoming easily annoyed or irritable*
  • Feeling afraid as if something awful might happen*
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

  • Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)

  • Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.

    For this questionnaire, please think about the worst event that has happened to you during your lifetime.

    In the past month, have you…

  • Had nightmares about the event(s) or thought about the event(s) when you did not want to?*
  • Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?*
  • Been constantly on guard, watchful, or easily startled?*
  • Felt numb or detached from people, activities, or your surroundings?*
  • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?*

  • Authorization for Release of Information (ROI)

  • This authorization allows Freedom Fighters Therapy LLC to release and/or obtain information necessary to coordinate your care, verify insurance or VA benefits, communicate with healthcare providers, and process referrals when authorized by you or required by law.

    You may revoke this authorization at any time in writing unless action has already been taken in reliance upon it.

  • Do you authorize Freedom Fighters Therapy LLC to release and/or obtain information for purposes of treatment, payment, and healthcare operations?*
  • Type of Information to be Released or Requested
  • Purpose of the Release

  • Revocation

  • I understand that I may revoke this authorization at any time by providing written notice to Freedom Fighters Therapy LLC.

    Revocation will not affect actions already taken in reliance upon this authorization.

  • Final Certifications and Electronic Signature

  • Please review the statements below carefully before signing.

    By electronically signing this intake packet, you acknowledge that you have read, understood, and agreed to all applicable policies, consents, financial agreements, and disclosures presented within this Master Intake Packet.

  • By checking each statement below, I certify that:*
  • Date*
     - -

  • Thank you for completing the Freedom Fighters Therapy LLC Master Intake Packet.

    Your information will be reviewed by our administrative team. If additional information is needed, we will contact you.

    If payment is required based on the services you selected, you will proceed to the secure payment page after clicking Continue.

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