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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:

Please fill out this field.

Preferred phone number:

Please enter a phone number.

Email address:

Please enter a valid email address.

Are you using VA Community Care?

Yes (approved)

Yes (pending approval)

Do you have a VA referral/authorization for massage therapy?

Yes

Not yet, but I want help getting one

Which VA clinic or provider do you use?

Please fill out this field.

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:

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Preferred form of communication:

Please fill out this field.