Within RANGE Counseling & Consultation Services, PLLC

Dr. Melissa Jenkins-Fernández: Florida 🏝️Licensed Psychologist (PY12372) & PSYPACT Provider (#4660)

Psychotherapy to Enhance Well-being, Skill-Sets, and Meaningful Connections From WITHIN Yourself. 🐴 Equine Inspired Psychotherapy that is short-term and supplemental to help both typical and neurodivergent adults and children who are at least 11 years-old IMPROVE well-being, emotional regulation, and anxiety from WITHIN themselves 🫏

🐳 You're Within Range of a Healing Journey

A Little Info About You

Is the consultation for you or a child?

Me My child (I am the Legal Guardian) A Child (Just Getting Information About Services)

(Example: Equine Professional or Not the Legal Guardian)

An Adult *Referral

*I am a Provider interested in adjunct services for my client

A Child *Referral (at least 11 years old)

*I am a Provider interested in adjunct services for my client

How old is the child?

Psychotherapy Location Options: 💻Virtual | 🏢Office | 🐴Barn

💻 Virtual (Telepsychology), including Eye-Movement Desensitization Reprocessing (EMDR) Therapy to 43+ PSYPACT States, a Territory, and a District

Do you prefer Virtual (Telepsychology Sessions) 💻 On-Line Psychotherapy in a HIPAA Compliant and Secure Platform

Yes No

PSYPACT & EMDR Certified

🏢 Office Psychotherapy

Do you prefer In-Office Psychotherapy at the Melbourne, FL Suntree Location 🏢 Limited Day(s) and Time Slots

Yes (I prefer in-office sessions) No

Inspiration for Your Healing Pathway Forward

🐴 Equine Inspired Psychotherapy (EIP)

Do you prefer Equine Inspired Psychotherapy (EIP)?🫏

Yes (All programs are ground-based, no riding) No

If You Are Reading This: You Are Within Range of a Healing Pathway Forward

🥕 Please note that Within Range provides ground-based🐴 Equine Inspired Psychotherapy (EIP) as a supplement to support the work already being done in psychotherapy. EIP, including Equine Facilitated-EMDR, is not typically a stand alone treatment but details will be discussed during the consultation call to see if services are a good fit. Provided at a 🏝️Cocoa, FL Barn Location

Experience with horses and donkeys ? Please type below

Horseback Riding, Equine Therapy, Grew Up with Them, Hippotherapy etc

Certifications

💲Fee & Payment Info

Within RANGE is self-pay only and does not accept Insurance (Out-of-Network)

Yes, I understand

I provide a receipt called a "superbill" for clients to submit to your insurance company for Out-of-Network reimbursement benefits

💲Within RANGE fees:

90-Minute Virtual Intake: $250
60-Minute Session: $200

🔸Fees for Additional Services are listed on the Informed Consent Document

Does your child receive a "Florida Step-Up For Students" Scholarship for Specialized Services for Mental health Care?

Yes No

Dr. Jenkins-Fernandez is a SUFS Provider

Brief Screening Questionnaire

Privacy Policy Within RANGE will not share your information provided on this form. Once you submit this form, it is sent to Hushmail's encrypted, secure and HIPAA compliant server.

Yes, I understand

Safety First ⚠️This form is NOT to be used for an emergency, as it is not monitored 24/7. Call 988 in an emergency.

Yes, I understand and do not have an emergency

Scope of Practice and Services

Within Range is a small specialized practice typically providing supplemental (adjunct) psychotherapy to individuals already in mental health treatment with a well-being focus and does NOT treat all disorders (e.g., conduct disorder, oppositional defiant disorder, intermittent explosive disorder etc.). Services are not appropriate for any individual with a history of arson, cruelty to animals, assault, and violence

✅ Yes, I understand and none of these apply

Are you currently involved with the legal system? Example: Charges pending or parental custody disputes?

Yes

Please briefly explain below

Please note that due to scope of practice, services are not offered for forensic cases (sex offenders) or for adults and children in current legal or custody disputes

Is your adult client currently involved with the legal system? Example: Charges pending or parental custody disputes?

Yes

Please briefly explain below

Please note that due to scope of practice, services are not offered for forensic cases (sex offenders) or for adults and children in current legal or custody disputes

Is your child currently involved with the legal system? Example: Charges pending or parental custody disputes?

Yes

Please briefly explain below

Please note that due to scope of practice, services are not offered for forensic cases (sex offenders) or for adults and children in current legal or custody disputes

Mental Health Info

Do you currently have a mental health treatment provider?

Yes No

Briefly Describe

Are you looking for adjunct (not primary) psychotherapy options for your client? Equine Inspired Psychotherapy, EMDR

Yes (Adjunct only) No

Briefly Describe

Does your child currently have a mental health treatment provider?

Yes No

Briefly Describe

Psychiatric Hospitalization within the last year?

Yes No Unknown

Please Briefly Explain

Contact Information

First Name (Person completing this form)

Last Name

Your Current Age

Phone Number

📞 Best Times for Return Call (M-F) EST Time Zone

Morning (7am to 11am) Afternoon (Noon to 5pm) Evening (5pm to 9pm) No Preference

You agree for Within RANGE to leave you a voicemail?

Yes *No

Within RANGE does not send text messages 🚫

*Within Range will make one phone call attempt from ☎️ 321-497-5500 at the listed number within your preferred window but will not leave a voicemail.

You agree for Within RANGE to reply through Hushmail to your e-mail to schedule the consultation call?

Yes No

📥E-mail Address

(Please be mindful of the e-mail you provide (e.g., personal account, employer, or school etc.) because it is where Within RANGE's consultation scheduling question is sent or an out of scope of service response.

Do you agree to an encrypted e-mail response?

Yes

(It is secure and HIPAA compliant. You will have to set up a password and provide your email on Hushmail's secure message center to view your encrypted message)

(An unencrypted e-mail response is sent directly from Hushmail to your email and is not regarded as secure if your email account is not already encrypted).

Consultation Info:

❓Reason(s) for seeking consultation:

Submit the form for a free 15-minute consultation

Thank you

By checking this box: 1) you agree and understand that submitting this form and receiving a response does not indicate a professional relationship of any kind and is for an initial 15-minute consultation for potential services only. 2) Services are only for individuals who reside in Florida or other PSYPACT location.

(Inquiries are only received by an authorized staff member and replies are typically within 48 hours of receiving the contact form)

Your information will be encrypted.

💻Virtual | 🏢Office |🐴Barn

Licensed Clinical Psychologist Serving 43+ States, a Territory, and a District from Florida’s 🚀Space Coast. Certified in 🍃Eye-Movement Desensitization and Reprocessing (EMDR) and🐴Equine Inspired Psychotherapy (EIP) to include Equine Facilitated-EMDR. She also specializes in treatment of Functional Neurological Disorder (FND) and facilitating ground-based EIP🫏

withinrangecounseling.com