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Intensive Application Form
Venn Med Team
2026-10-03T18:37:36+00:00
Intensive Program Application
Application form for patients considering an intensive
Intensive Therapy Program Application Form
This form is used to screen for fit and suitability before scheduling an Intensive. Your answers help our clinical team confirm you're a good candidate, flag anything requiring medical clearance first, and recommend the right tier and team for your NeuroPerformance Evaluation.
Applicant Information
Name
First
Last
Date of Birth
Month
Day
Year
Email
Phone Number
Preferred Contact Method
Phone
Email
Text
Presenting Condition
Presenting Condition(s) - check all that apply
Post-Concussion Syndrome / mTBI
Vestibular dysfunction / BPPV / Vertigo
Chronic Dizziness / Imbalance
Visual-Vestibular Mismatch / Oculomotor Dysfunction
Cognitive Fog / Processing Speed Concerns
Functional Neurological Disorder (FND)
Dysautonomia / POTS
Migraine / Vestibular Migraine
Chronic Pain
Other (please specify below)
Other / Additional Detail
Date of Onset
Month
Day
Year
Symptom Trend
Stable
Worsening
Improving
Intermittent
Prior Care and Diagnostics
Prior Care and Diagnostics
Prior Physiotherapy / rehabilitation for this condition
Prior neuro-optometry / vision therapy
Prior neuropsychological or cognitive testing
Prior vestibular therapy
Prior imaging (CT/MRI) - please attach report if available
Currently under care of another provider for this condition
Current Health Care Practitioner Managing
Time Spent In Treatment
Success
Failure
Why or Why Not?
Attach Imaging / Diagnostic Reports
Max. file size: 50 MB.
Safety Screening
Please check any that currently apply. These don't disqualify you, but may require medical clearance before your Intensive is confirmed.
Unexplained Weight Loss
Loss/Change of Bowel / Bladder Control
Currently Pregnant
Uncontrolled Seizures / Epilepsy
Unstable Cardiac Condition
Active Suicidal Ideation or Acute Psychiatric Crisis
Acute Trauma
None of the above applies to me
Intensive Format Preference
Intensive Format Preference
Half-Day Intensive - Single concentrated session - ideal for mild/early stage symptoms
Full Day Intensive - One day multimodal care for moderate symptom load
3 Day Intensive - Multi-day compressed program for persistent or complex symptoms
1 Week Intensive - Comprehensive week long program for complex, longstanding presentation
Preferred Start Date Range
Scheduling Constraints
work, school travel
Readiness for an Intensive
Do you have reliable transportation to/from the clinic each day
Yes
No
Do you have support at home during/after intensive days (for rest, recovery, supervisions if needed)
Yes
No
Limited
Are you able to pause work/school obligations for the duration of the intensive?
Yes, fully
Partially
No
What outcome(s) are you hoping to achieve? (e.g., return to work/sport/driving, reduce dizziness, improve tolerance to screens/crowds)
Consent and Acknowledgement
Consent and Acknowledgement
I confirm the information provided above is accurate to the best of my knowledge. I understand this form is used to screen my suitability for the Neurorehabilitation Intensive, that acceptance is subject to clinical review and a NeuroPerformance Evaluation, and that my final program tier, schedule, and treating team will be confirmed following this assessment. I consent to Venn Med™ collecting and using this information for the purpose of intake screening and care planning.
I have read and agreed to the above*
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