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Helpful Forms

[Updated 01-31-2017]

If you're a new client, ask me about the following forms. [Quick link to Extra documents below.]

Signature Instructions:

1. Distance clients: To sign digitally, download and read the documents, then attach them to an email containing your name and date and Subject: Signature.  
Please remember that this is not an encrypted communication system.

2. In-Office clients: You may use the same process as in #1. Or,  you may print and bring these with you to the office at the time of your appointment.


Main Set:

"
Patient Assessment Form- PAF" (helpful for international consultations): 
 PDF version | RTF version  

"Coaching Assessment Form- CAF" (helpful for international consultations):  PDF version | RTF version  | MS Word version

Informed Consent for consultation or coaching with Dr. Wilson:

Informed Consent [MS W

Informed Consent for Counseling [PDF]


Informed Consent for Counseling [MS Word]

Informed Consent for Coaching [PDF]

Informed Consent for Coachling [MS Word]

     [Additional commentary page on this site: Informed Consent]

Notice of Privacy Practices: Download [PDF]

Arbitration Agreement: [PDF]

No Self-Harm Contract:  PDF version | MS Word version
 


Iridology Forms Set -- for Focused Iridology Appointments and Research option

"Patient Assessment Form- PAF" (helpful for international consultations):  
PDF version  | MS Word version

Informed Consent [MS Word] 

Notice of Privacy Practices: Download [PDF]

In addition, if you have been referred by an outside physician or clinic for Focused Iridology appointment, please read this statement: I provide iris photogaphy and iridology assessment as part of a larger framework of interpretation. I also require the above forms (PAF and Informed Consent) so that I can be assured that I have the best opportunity to discover what is called "the root cause" of a person's concern about health of body or mind. You are invited to read more about Iridology Science on my Information Site [click here].

 


Amen Clinics Forms:

 

  • Adult Intake, FemalePDF format [Contains sections: Adult Intake questionnaires , Psychiatric and Medical History, Amen Adult General Symptom Checklist, Amen Brain System Checklist, Amen Learning Disability Screening Questionnaire, Female Hormone Health Questionnaire, Medical Review Checklist, Neuropsychiatric Symptom Checklist, Amen Clinic Brain SPECT Informed Consent Form]

 

  • Adult Intake, MalePDF format  [Contains sections: Adult Intake questionnaires , Psychiatric and Medical History, Amen Adult General Symptom Checklist, Amen Brain System Checklist, Amen Learning Disability Screening Questionnaire, Male Hormone Health Questionnaire, Medical Review Checklist, Neuropsychiatric Symptom Checklist, Amen Clinic Brain SPECT Informed Consent Form]
 
  • Amen Clinics Referral from Dr. Wilson -- Reston VA clinic [PDF format]
  • Amen Clinics Referral Nationally or Overseas [PDF format]

Stephen Porges, Ph.D. form:

Body Perception Questionnaire -- "...The BODY PERCEPTION QUESTIONNARIE has five sub-tests: 1) Awareness, 2) Stress
Response, 3) Autonomic Nervous System Reactivity, 4) Stress Style, and 5) Health History Inventory [PDF format] His site.


Options:

Pre-consultation Lab Testing with International testing option [more]

NuPathways PAK Questionnaire: PDF version | RTF version | MS Word version

"Psychometabolic Questionnaire" from WholePsychiatry.com: PDF version | RTF version | MS Word version

Sleep Medicine information re Sleep and Apnea: Epworth Sleepiness Scale | Berlin Questionnaire [PDF]
 


If you are a Veteran [Note to families: Please be sure your Veteran knows this]:
VA Health Care and the Affordable Care Act

If you are a Veteran who isn't enjoying the benefits of VA health care enrollment, please apply for VA health care. You may apply online at: www.VA.gov/healthbenefits/enroll. You can also visit your local VA halth care facility. Or, call 877-222-VETS (8387) to apply by phone.

Affordable Care Act considerations:  You can download this document that describes your current benefits and reassures with the following text:  "How is my VA health care coverage affected?" ANS: Nothing in the health law changes your VA care benefits. You can continue to use VA for all of your health care needs or complement your VA care with private health insurance or coverage by other federal health care programs, including Medicare, Medicaid and TRICARE. 
Download Full Document of Frequently Asked Questions about VA Health Care: Click Here -- PDF


Extra Information:

Advanced Directive Support -- Visitation: Wallet card and information for family, supporting Dr. Wilson visiting you in Hospital, Hospice or Home visits. [View PDF]

Essays and Informative documents:


Dr. Stephen Porges: "How Your Nervous System Sabotages Your Ability to Relate" [View PDF]

FlexAware Fitness/Neuro-Structural Rehab support [PDF format]:
"Create My FlexAware Habit" | FlexAware Self-Assessment Log

Your Health Menu: Insights about planning for your next choices in health care [View PDF]

Lifestyle of Healing: Updated for including acupuncture theory [View PDF]
Unresolved Emotions, from Acupuncture theory, Five-Element Emotional Correlations: 
Five Element Unresolved Emotions PDF 

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Helpful Forms

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