TeleHealth Intake Form

Fields marked with an * are required

Basic Information
Names Of Individuals
Devices
Technology Experience

Name *

Date Of Birth *

Have you used telehealth services before? *

Please list possible locations for future telehealth visits. (list up to 2)
Please indicate your current address

First Address

This is my current address
This not my current address

Second Address

This is my current address
This not my current address

Our staff will design an individualized treatment plan specific to your needs bringing together body, mind, and spirit. At Virtuous Wellness Center we provide you with the best and most affordable service to meet your needs.