Apply to Work With Us Functional Primary Care Advanced Functional Medicine Learn more about our membership models. Application for Advanced Functional Medicine "*" indicates required fields Step 1 of 12 8% This application will require 15–30 minutes to complete. Please answer questions thoroughly. Applicant ClarificationWho is this application for? For Me For a Dependent Your Contact InformationMy Name* First Last My Email* *My* Email Confirm *My* Email Applicant Phone*Dependent InformationDependent Name* First Last Dependent AgeHow old is your dependent?Dependent Email OptionWe need a unique email for your dependent, but if you don’t have a second email, we can help you to generate an alias that will still send emails to your email. I’ll provide a second email Please generate a system alias Dependent Email* *Dependent* Email Confirm *Dependent* Email Previous ExperienceFamily Connections*Are any of your family members active members with Richmond Integrative & Functional Medicine? Yes — I am an active member with RIFM Yes — Someone else in our family is a member. No — No one in our family is an active member. Member Connection* First Last Previous Experience*Have you previously worked with any of our providers? (Check any that apply) Aaron Hartman Christian Jenski Jodi Caddell No previous experience Health InsuranceInsurance Check*Do you have a standard health insurance plan? Yes No Membership with RIFM is still possible without health insurance, but would require paying for visits and any labwork out-of-pocket.Payment Intention*How would you intend to pay for office visits? I will pay for office visits with cash I am part of a group sharing plan Insurance Provider*Please select your insurance provider: Aetna Anthem (Blue Cross / Blue Shield) Cigna Humana Medicare Multiplan United Healthcare Other Other Insurance*Please provide:Insurance Plan*Which type of plan do you have? HMO PPO EPO Other RIFM does work with the insurance provider you have provided for most standard HMO & PPO plans. However, because you have listed “other,” for your plan, we cannot pre-qualify you. Please proceed with the rest of the application, but we will need to clarify your insurance. Unfortunately, RIFM does not participate in the insurance network you’ve provided. Membership with RIFM is still possible without health insurance, but would require paying for visits and any labwork out-of-pocket.Payment Follow-UpWould you be able to pay for office visits with cash (i.e. out-of-pocket)? Yes, I will pay for office visits with cash No, I cannot pay for visits without insurance Parent NotePlease fill out the following section on behalf of the dependent. Any references to “you” or “your” should be considered your dependent.Overall HealthOn a scale of 1–5, how happy are you with your present health?*TerribleNot so greatNeutralPretty goodExcellentHealth ConcernsPrimary ConcernWhat is your main health concern?Frequency of Concern*How often does it bother you? Every day 2 – 3 times per week Once per week Once per month Duration of Concern*How long has it been going on? 1–6 months 1–3 years Over 3 years Progress / SetbacksProgress/Setbacks*What have you tried so far that has or has not worked? Current DietPlease describe your current diet.Diet Frequency*How often do you eat per day? Less than twice per day 2–3 times per day 3 meals per day (no snacks) 3 meals plus occasional snacks 3 meals plus frequent snacking Frequent, intentional grazing Frequent, unintentional grazing Typical Breakfast*Typical Lunch*Typical Dinner*Typical Snacks*Lifestyle Challenges*What obstacles, challenges, and struggles do you face regarding diet/lifestyle? Medications & SupplementsAre you currently taking any medications or supplements? Please list anything you take and it’s intended purpose.Medications and SupplementsWhat You’re TakingIntended Purpose Add Remove Health GoalsHealth Goals*What would you like your health to be 6 months from now? Expected OutcomesExpected Outcomes*If we were to work together what would you expect to achieve from working with us? Potential BarriersObstacle List*What (or who) would prevent you from completing a functional medicine program or plan (e.g., lifestyle changes, supplement supports)? Children Spouse/Partner Money Self Job Fear Time None of these Barrier Clarification: ChildrenPlease elaborate: How would your children create a barrier to completing a functional medicine program?Barrier Clarification: PartnerPlease elaborate: How would your spouse or partner create a barrier to completing a functional medicine program?Barrier Clarification: MoneyPlease elaborate: How would money create a barrier to completing a functional medicine program?Barrier Clarification: SelfPlease elaborate: How would you create a barrier to completing a functional medicine program?Barrier Clarification: JobPlease elaborate: How would your job create a barrier to completing a functional medicine program?Barrier Clarification: FearPlease elaborate: How would fear create a barrier to completing a functional medicine program?Barrier Clarification: TimePlease elaborate: How would time create a barrier to completing a functional medicine program? This field is hidden when viewing the formNumber of LovesPlease enter a number from 5 to 5.5 Loves*What are 5 things you LOVE about your life? Add Remove Δ
