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Tele-Behavioral Health Protocol
(To be filled out by veteran)
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* Indicates required question
Veteran Name:
*
Your answer
Veteran DOB:
MM
/
DD
/
YYYY
Veteran Last 4 of SSN:
Your answer
Veteran Phone Number:
Your answer
All locations in which you will/could use for your tele-behavioral health session:
Location description: Home/work/school/etc and Location address:
Your answer
Veteran’s Emergency Contact
Emergency Contact Name and Emergency Contact Telephone Number
Your answer
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