Veteran Pre-Screening – VA Community Care
This form is for veterans interested in receiving medical massage therapy through VA Community Care.

Please complete this short screening so I can guide you through the referral and scheduling process.
Date:*
Full Name:*
Preferred phone number:*
Email address:*
Are you using VA Community Care?*
Yes (approved)
Yes (pending approval)
No
Do you have a VA referral/authorization for massage therapy?
Yes
No
Not yet, but I want help getting one
Which VA clinic or provider do you use?
What are you seeking help with?
Pain relief
Muscle tension
Injury recovery
Mobility issues
Stress / tension
Other: _______
When are you looking to begin care?*
As soon as possible
Within a few weeks
Just exploring options
Best time to call:*
Preferred form of communication:*
Anything you'd like me to know before I reach out?*