EXPERIENCE THE JOURNEY OF RECOVERY WITH VIRTELCO Please answer the questions to the best of your knowledge by choosing the appropriate answer. All answers will be confidential and shared only with the therapist to deliver effective treatment program. Step 1 of 5 20% 1. Are you in need of using Virtual and Rehabilitation services?(Required) YES NO 2. Are you in need of occupational therapy or speech-language pathology but you live in a remote area and don’t have access to the clinics?(Required) YES NO 3. Are you/your children suffering from(Required) Multiple Sclerosis (MS) Migraine Epilepsy Neck and back pain Stroke None Other 4. Are you/your children suffering from(Required) Articulation Disorders Stuttering Aphasia Voice Disorders None Other CLIENT INFORMATIONPlease answer the questions to the best of your knowledge by writing the appropriate answer. All answers will be confidential and shared only with the therapist to deliver effective treatment program.Personal InformationFull Name(Required) Gender(Required) Male Female Age(Required) Date of Birth(Required) MM slash DD slash YYYY Address(Required) City(Required) State(Required) Post Code(Required) Home Telephone Number(Required)Email Mobile Telephone Number(Required)Emergency Contact InformationFull Name(Required) Phone Number(Required)Relationship(Required) How did you hear about us?(Required) Are you insured for any health care? If yes, under which insurer or plan(Required) Medical History Information1. Have you ever been hospitalized? If yes, please provide details.(Required) 2. Have you had any surgeries? If yes, please provide details.(Required) 3. Do you have any allergies? If yes, please provide details.(Required) 4. Do you have any chronic medical conditions? If yes, please provide details.(Required) 5. Do you have a history of mental health conditions? If yes, please provide details.(Required) 6. Do you have a history of substance abuse? If yes, please provide details.(Required) 7. Do you have a family history of medical conditions? If yes, please provide details.(Required) CAPTCHA
