Veteran Services Inquiry

IMPORTANT NOTE:

Once you submit this form, Dr. Rodriguez will review it and you will receive a follow-up via email within a few days. Please check your spam and junk mailbox just in case it doesn't go to your inbox. In the unusual event that you do not hear from us, please contact us at contact@amicaclinicalconsulting.com

Please answer the questions below to determine whether our services may be of help at this time. We do this because we do not want you to pay for our services if we cannot provide a psychological opinion.

This consultation form is encrypted and secure for your privacy.

Do you consent to receiving a response to this request via email?

Yes

If you do not consent, we cannot use email to communicate with you. You may call us by phone, but this may take a little longer to respond to.

What type of mental health condition do you want us to address? We can ONLY diagnose mental health conditions.

DEPRESSIVE DISORDERS SUCH AS: Depression, Dysthymic Disorder or Persistent Depressive Disorder, Major Depression, Unspecified Depressive Disorder, Disruptive Mood Dysregulation Disorder, or another Depressive Disorder

BIPOLAR DISORDERS SUCH AS: Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, Unspecified or Specified Bipolar Disorder

ANXIETY DISORDERS SUCH AS: Specific Phobia, Social Anxiety Disorder (Social Phobia), Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Other Specified Anxiety Disorder or Unspecified Anxiety Disorder

TRAUMA AND STRESS DISORDERS SUCH AS: Post-Traumatic Stress Disorder, Adjustment Disorder, Other Specified Trauma- and Stressor-Related Disorder, Unspecified Trauma- and Stressor-Related Disorder

PSYCHOTIC DISORDERS SUCH AS: Schizotypal (PSchizophreniform Disorder, Schizophrenia, Schizoaffective Disorder, Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified, Schizophrenia Spectrum and Other Psychotic Disorder

Somatic Symptom Disorder

Other

please indicate what mental health conditions you would like help with below

A mental health condition secondary to a physical condition

please indicate what mental health condition you want to address and what medical condition it is related to

What mental health condition do you want us to help with?

Has a mental health provider already diagnosed you with the mental health condition that this claim is related to?

Yes No

What Type of Claim Is this Consultation Related to?

I have never filed for service connection for mental health; I will be filing for the first time

I have filed for mental health but was denied

I am service connected for mental health but am filing for an increase

What conditions are you currently service-connected for?

If none, please write none.

Do you have the Veteran's relevant military records, claims file/C-File (if you've filed claims already), written Veteran/Buddy/Family statements, AND any relevant medical records?

If there is a claims file, we must review it.

Yes

What type of service are you seeking?

A nexus letter only

This is based on a review of your records only. Dr. Rodriguez will NOT diagnose you. She will only offer an opinion on whether your current diagnosis of record is linked to time in service or another service-connected condition.

A DBQ Exam (and Nexus Letter if you need it)

This requires an exam with psychological testing

I only want a psychological evaluation for a diagnosis and treatment recommendations

You understand that this is not a disability exam and I cannot complete a DBQ form with this type of evaluation.

I'm not sure

Please discuss with a VA accredited representative for advice; we are not able to provide you with claims advice.

Please provide any additional information that you think might be helpful for Dr. Rodriguez to determine if she can assist you.

EMAIL ADDRESS

FIRST NAME

LAST NAME

Do you consent to receiving informational, educational, marketing, and practice updates from Dr. Rodriguez/Amica Clinical Consulting PLLC via email??

Yes

Are you represented by a Veterans Service Officer, VA-accredited Claims Agent, or a VA-accredited Attorney?

You can find an accredited representative here: https://www.va.gov/ogc/apps/accreditation/index.asp

Not Sure

You can find an accredited representative here: https://www.va.gov/ogc/apps/accreditation/index.asp

Yes

How did you find us?

Google or Internet Search / Website

VSO

Friend or Family Member

Facebook Group

Therapist, Doctor, or Other Healthcare Provider

Other

HIPAA Notice of Privacy Practices

How Our Services Work

Step 1: Complete the free consultation form (this one). You will receive a response directly from Dr. Rodriguez as soon as possible (often on the the same day). If you are requesting a nexus letter or DBQ exam for a condition Dr. Rodriguez is trained to address, she will let you know and you can move to Step 2.

Note: If you only want a clinical evaluation (not for disability), she will ask you to schedule an appointment with her online.

Step 2: Record Review. You will receive a link to register in the patient portal, sign forms, upload your documents/records, and make payment. You will receive an invoice for $250 for the record review. Dr. Rodriguez will conduct the record review and will message you to notify you if she thinks:

1. She has enough information and CAN provide the service you requested (proceed to Step 3)

2. She cannot provide the service you requested or that she needs more records/information to make a decision (she will tell you what information that is).

Step 3: Nexus Letter Research and Writing or Scheduling of Exam. Dr. Rodriguez will schedule you for your DBQ exam and documentation completion ($2750). If you are only obtaining a nexus letter (Nexus Letter for One Mental Health Diagnosis: $500; Nexus Letter for Two+ Diagnoses: $745), then Dr. Rodriguez will start working on your nexus letter and research for the nexus letter. As soon as Dr. Rodriguez is done, you will be informed via secure message/email. You will receive your document via email or secure portal.

IMPORTANT: It is important that you understand that Dr. Rodriguez is an independent evaluator. This is very different than a therapist. She is not your therapist and does not provide treatment to you. This means that she is neither on your side nor on the VA's side. Her role is to provided an unbiased psychological opinion about your mental health and/or mental health disability. She will use psychological testing to help her evaluate you for DBQs and psychological evaluations. She makes NO guarantee that she can provide you with the results you want. However, she is thorough in her evaluations and will review all information you provide that is relevant, including buddy statements, family statements, and Veteran statements.

By When Do You Need All of the Documents Completed?

What State Do you Reside In?

Your information will be encrypted.