PART 1: PERONAL INFORMATION
Name *
Name
Gender
Address
Address
Phone
Phone
Are you currently employed?
If employed, terms of employment
PART 2: MILITARY HISTORY
Branch
Terms of Service
Served in Combat
If yes, please indicate dates of service in combat
DD214
PART 3: MEDICAL HISTORY
Are you a recipient of VA Benefits?
Insurance Carrier
**If you currently do not carry insurance, please leave blank
Type, Dosage, and Frequency
Type, Dosage, and Frequency
PART 4: MENTAL HEALTH
History of Mental Health Treatment
Select yes if you have recieved any treatment for mental health related symptoms. Some of the most common are the following: talk therapy, psychiatric treatment, EMDR therapy, or Neurofeedback
Please list any current or past mental health diagnoses
Question 1
Do you have repeated and disturbing memories, thoughts, or images from past stressful experiences?
Question 2
Do you experiences disturbing dreams or nightmares from past unpleasant experiences?
Question 3
Do you sometimes feel as though you are reliving past stressful experiences?
Question 4
Do you have physical reasctions to things that remind you of stressful experiences? These could include pounding or increased heart rate, sweating, dizziness, shaking, increased breathing, upset stomach, etc.
Question 5
Do you avoid people, places, events, or conversations that remind you of stressful experiences? This can also include trying not to feel any emotions that may be associated to these things.
Question 6
Do you have difficulty remember all or parts of stressful past experiences?
Question 7
Do you feel distant or cut-off from other people?
Question 8
Do you feel numb, like you have very little or no emotional responses?
Question 9
Do you feel like you have lost interest in things that you used to enjoy?
Question 10
Do you have trouble falling asleep? Or do you wake up frequently throughout the night?
Question 11
Do you feel angry, have a lower stress tolerance, or notice that you have a shorter temper than usual?
Question 12
Do you feel like you are on guard, or hyper aware of sounds, sights, smells, or movement in your enviornment?
Question 13
Do you get startled easily from sudden noises, or feel on edge or jumpy?
PART 5: ESSAY
Please provide a brief essay, no more than 250 words, about why you are interested in participating in the Because Council project.
PART 6: ADJUNCT SERVICES
Would you or a family member be interested in learning more about the supportive services we offer in our clinic?
Please indicate areas of interest.

VETERANS

We are proud to announce the launch of our new Because Council project dedicated to the growth and future development of our veterans.

To set up an appointment please contact us via email or phone.

Email: veterans@urbanbrainandbody.com

Phone: 312-257-8550

For more information and a video on neurofeedback's effects on PTSD check out www.p-t-s-d.com.

Google+