Eligibility Form Individual Eligibility Form Submitter Name Enrollee Name (if different than submitter) Employer Name Phone Email Address Best Time to Reach You Primary Care Physician Primary reason for seeking services (eg. anxiety, depression, nutrition) Visit Type Preference Visit Type Preference In-Person Telehealth ViCare Guide Preference ViCare Guide Preference Male Female On a scale from 1 (worst) to 10 (best) what is your current overall sense of well-being? (eg. physical, emotional, spiritual, etc.) On a scale from 1 (worst) to 10 (best) what is your current overall sense of well-being? (eg. physical, emotional, spiritual, etc.)12345678910 Additional information you'd like to share with us Submit
