Veteran Services Inquiry

IMPORTANT NOTE:

We are an online practice. Initial inquiries are addressed via email. We are not able to provide phone consultations at this time.

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.

Be sure to read all of the available information on our website BEFORE submitting this request for information. We are not able to respond to inquiries requesting services outside of our scope of practice, sales/solicitation inquiries, or other inquiries not relevant to the services we offer. For example, if you are requesting services related to diagnosing sleep apnea or other medical conditions for disability, this is outside our scope. Please review our website for details on conditions we can address. For example, we can address depression/anxiety secondary to a chronic pain condition, but we cannot address sleep apnea related to PTSD.

Also, please note that we are not currently providing nexus opinions based only on record review. We must conduct a psychological examination.

This consultation form is encrypted and secure for your privacy.

What type of service are you seeking?

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

This requires an exam with psychological testing. This is typically a 3-4 hour examination via video.

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

You understand that this is not a disability exam and a DBQ form cannot be completed with this type of evaluation. You will be asked to schedule a different type of appointment than the one addressed in this form.

I'm not sure

DO NOT SUBMIT THIS REQUEST AT THIS TIME. Please discuss with a VA accredited representative for advice PRIOR to submitting a consultation/inquiry request; we are not able to provide you with claims advice or suggest services in this situation.

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

Yes

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

Please provide any additional information that you think might be helpful to determine if we might be able to assist.

EMAIL ADDRESS

FIRST NAME

LAST NAME

Do you consent to receiving informational, educational, marketing, and practice updates from 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 as soon as possible. If, based on the information you share, we think we may be able to provide the requested service, we will reply via secure email regarding Step 2.

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. We will conduct the record review and will message you to notify you if we think:

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

2. We cannot provide the service you requested or we need more records/information to make a decision about whether to move forward.

Step 3: Scheduling of Exam. We will schedule you for your DBQ exam and documentation completion ($2750). Once your evaluation is complete, tests are scored and interpreted, and your results are ready, you will be informed via secure message/email. You will receive your documents (report and relevant completed DBQ form) via email or secure portal.

IMPORTANT: It is important that you understand that we are serving as independent evaluator. This is very different than a therapist. We are not your therapist and do not provide treatment to you. Our role is to provided an unbiased psychological opinion about your mental health and/or mental health disability. We will use psychological testing to help evaluate you. We make NO guarantee that we can provide you with the results you want. However, we are thorough in conducting 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.