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 Clarification Who is this application for? For Me For a Dependent Your Contact Information My Name* First Last My Email* *My* Email Confirm *My* Email Applicant Phone* Dependent Information Dependent Name* First Last Dependent AgeHow old is your dependent? Dependent Email Option We 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 Experience Family 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 Insurance Insurance 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-Up Would 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 Note Please fill out the following section on behalf of the dependent. Any references to “you” or “your” should be considered your dependent. Overall Health On a scale of 1–5, how happy are you with your present health?* TerribleNot so greatNeutralPretty goodExcellent Health Concerns Primary 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 / Setbacks Progress/Setbacks*What have you tried so far that has or has not worked? Current Diet Please 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 & Supplements Are you currently taking any medications or supplements? Please list anything you take and it’s intended purpose. Medications and Supplements What You’re Taking Intended Purpose Add Remove Health Goals Health Goals*What would you like your health to be 6 months from now? Expected Outcomes Expected Outcomes*If we were to work together what would you expect to achieve from working with us? Potential Barriers Obstacle 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 form Number of Loves Please enter a number from 5 to 5. 5 Loves* What are 5 things you LOVE about your life? Add Remove Δ
