VICARE Participant Intake Form
Please take time to fill out all questions of this form. This information will help us better curate programming to your needs.

Informed Consent Here.

I have read, understand, and agree to the Informed Consent?
Name (Last, First)
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
Email
Your answer
Phone
Your answer
Branch of Service
Service Status
Enlist Date
MM
/
DD
/
YYYY
DD 214 Issuance Date
Your answer
Description of Disability(s)
Your answer
Are You Experiencing Stress/Anxiety?
Are you currently experiencing suicidal thoughts?
If you are experiencing suicidal thoughts at what intensity?
Low
High
Do you have a plan or are you concerned you may attempt suicide?
General Intensity of Anxiety
Low
High
Frequency of Anxiety
Infrequent
Frequent
What areas of your life cause the most anxiety?
Describe any experience of emotional pain in your own words.
Your answer
Describe Emotional Triggers
Your answer
Level of Stress Related to Finances
Low
High
Level of Stress Related to Family
Low
High
Level of Stress Related to Spouse
Low
High
Level of Stress Related to Work
Low
High
Level of Stress Related to Physical Pain
Low
High
Level of Stress Related to Public Places
Low
High
Level of Stress Related to Driving
Low
High
Levels of Stress Related to Unemployment
Low
High
Levels of Stress Related to Legal Struggles
Low
High
Level of Stress Related to Grief and Loss
Low
High
Level of Stress Related to Isolation/Lack of Connection with Others
Low
High
Level of Stress Related to Loss of Physical Activity
Low
High
Level of Stress Related to Pain
Low
High
Level of Emotional Pain Related to Family
Low
High
Level of Emotional Pain Related to Marriage
Low
High
Level of Emotional Pain Related to Work
Low
High
Level of Emotional Pain Related to Unemployment
Low
High
Level of Emotional Pain Related to Healthcare
Low
High
Level of Emotional Pain Related to Legal Issues
Low
High
Level of Emotional Pain Related to Grief and Loss
Low
High
Level of Emotional Pain Related to Isolation/Lack of Connection with Others
Low
High
Level of Emotional Pain Related to Loss of Physical Activity
Low
High
Level of Emotional Pain Related to Physical Pain
Low
High
Intensity of Physical Pain
Low
High
Frequency of Physical Pain
Low
High
Quality of Sleep
Low
High
Quality of Sex Life
Low
High
Level of Joy Related to Family
Low
High
Level of Joy Related to Marriage
Low
High
Level of Joy Related to Work
Low
High
Level of Joy Related to Friendships
Low
High
Level of Joy Related to Physical Activity
Low
High
Please list any pharmaceuticals/medications you are taking currently (optional)
Your answer
Please list any accommodations you would like available, e.g. wheelchair, crutches, pillows, blankets, toiletries, etc.
Your answer
Please list any food/diet restrictions
Your answer
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