Within RANGE Counseling & Consultation Services, PLLC

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

🐴 Equine Assisted Psychotherapy that is short-term and supplemental to help both typical and neurodivergent children who are at least 11 years-old IMPROVE well-being, emotional regulation, and anxiety from WITHIN themselves 🫏

The Courageous Sea Turtle

You Are Within Range of a Healing Pathway Forward

Equine Inspired Psychotherapy

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

SUFS Provider

Within RANGE is accepting NEW adolescent clients for short-term psychotherapy for adolescents receiving Florida's "Step Up For Students" Funding

Yes, I understand

My child already has a "Step Up For Students" Scholarship that covers mental health services

What SUFS Scholarship program is your adolescent receiving?

Is the Florida Parent/Legal Guardian an Active Duty Military Service Member

Yes No

Brief Screening Questions to Ensure a Good Fit for Services

Within Range is a small specialized practice and does NOT treat all behavioral health conditions (e.g., conduct disorder, oppositional defiant disorder, intermittent explosive disorder, etc.) Services are not appropriate for any adolescent with a history of arson, cruelty to animals, assault, and violence

✅ Yes, I understand and none of these apply

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

Yes No

Please briefly explain below

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

Please confirm your adolescent is at least 11 years old

Yes

Current Age of your Adolescent

Psychotherapy Services (In-Office and Equine Assisted)

Are you interested in In-Office Psychotherapy or 🐴 Equine Assisted Psychotherapy for your adolescent?

In-Office Psychotherapy (EMDR, CBT)

Melbourne, Florida Suntree Location

🐴 Equine Assisted Psychotherapy (Equine Assisted-EMDR, Equine Inspired Psychotherapy)

Cocoa, FL Barn Location

Please note that Within Range provides 🐴 Equine Assisted Psychotherapy as a supplement to support the work already being done in psychotherapy and is not typically a stand alone treatment but details will be discussed during the consultation call to see if services are a good fit.

What is your child's experience around horses and donkeys? Please type below

Is your adolescent currently receiving mental health services?

Yes No

Has your adolescent received mental health services in the past?

Yes No

💲Within RANGE fees:

90-Minute Virtual Intake: $250

60-Minute Psychotherapy Session: $200

Fees for Additional Services are listed on the Informed Consent Document

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

Adolescent Mental Health Information

Adolescent's First Name

Where is your adolescent receiving mental health treatment?

Where was your adolescent receiving mental health treatment?

Mental health diagnosis/conditions

Any history of psychiatric hospitalization?

Prescribed psychiatric medication?

What are your adolescent's mental health concerns?

Adolescent Physical Health Information

Please list any diagnosed physical health conditions

Prescribed medication?

Parent/Legal Guardian Information

First Name

Last Name

Your Current Age

Contact Phone Number

Best Times to Return Your 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).

SUFS

Psychotherapy Options

❓Reason(s) for seeking consultation:

Submit the form for a free 15-minute consultation call

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 and receive the Step Up For Students scholarship authorized for mental health services

(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.

Florida Licensed Clinical Psychologist who is certified in 🍃Eye-Movement Desensitization and Reprocessing (EMDR) and🐴Equine Assisted Psychotherapy and Learning to include Equine Assisted-EMDR. She also specializes in treatment of Functional Neurological Disorder (FND) and facilitating ground-based Equine Inspired Psychotherapy (EIP) 🫏

(321) 497-5500
withinrangecounseling.com