Consultation Application

Application Form

Dr. van der Kolk is not accepting new patients at this time, but please feel free to submit the form below to be placed on a waitlist for a one-time consult.

First Name

Last Name

Phone #

Age

City, State, Country

Place of residence and how long

What specific issues would you like help with?

What are the 2 or 3 most relevant sections in The Body keeps the Score that make you reach out for a consultation.

Describe your family background

Martial Status

Number of children

List any professional or leisure interests

Who in your current life is important to you?

How many hours do you watch television?

Do you practice any of the following regularly?

Meditation

Yoga

Play Music

None of the above

What do you consider to be your strengths?

What has been successful in your life and what has not been successful?

List any medical conditions

List current and past medication

List any prior therapy treatment and how long

List prior hospitalization and how long

What is your preferred method of contact?

Phone Call

Text

Mail

Check all that apply.

Consultation

Application Form

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