New Patient Assessment Form

Welcome! Let's Begin Your Assessment. Thank you for taking this courageous step toward a new chapter in your health. We believe your symptoms are real, your experiences matter, and you deserve personalized care that works.

This assessment is the first step in our Immune Confident 4R journey together:

✨ Recognize: We'll help you identify the unique patterns in your health story.

✨ Reclaim: Discover a path to take back control of your well-being.

✨ Rebel: Move beyond one-size-fits-all answers to find what truly works for you.

✨ Rise: Create the foundation for lasting immune confidence and vitality.

Please share your story with us through this brief assessment. Our clinical team will carefully review your responses, honoring your unique experience and helping you determine if we are the right team to partner with you on your healing journey.

Your information remains completely confidential and will be reviewed with compassion by our licensed medical professionals.

Tell Us a Little About You

Let's start with the basics. This information helps us create your secure initial record.

Full Name

Email *

Phone *

Date of birth *

Sex Assigned at Birth *

Gender Identity

Pronouns

Tell Us About Your Health Story

This is the most important part of your application. Please be as detailed as you feel comfortable. Your story matters here.

Briefly, what are your primary health concerns you're seeking help for? *

How long have you been experiencing these primary concerns? *

What diagnoses, if any, have you already received from other providers?

What types of treatments or therapies have you tried in the past for these concerns?

How are these health concerns currently impacting your daily life? *

Where will you be located during your visits?

For telehealth medical care, our practitioners must be licensed in the state where you are physically located at the time of your appointment. Please select your state below.

What is your current state of residence? *

Your Desired Consultation

Please select the initial evaluation you are most interested in. Our clinical team will review your full application to confirm the most appropriate visit type for your needs.

Which of our initial evaluations are you most interested in? *

Your Path to Care From Out-of-State

As you are outside our licensed states for telehealth, our pathway to care is our premier in-person experience, the ICI Health Catalyst Journey. This involves strategic planning and travel to our clinic in Ohio. Please confirm your interest below.

What is your primary motivation for considering the ICI Catalyst Journey? *

I understand that the ICI Health Catalyst Journey requires in-person visits in Ohio and I am willing to travel to receive care. *

Yes

Please confirm your willingness to travel.

Envisioning Your Path to Wellness

Your answers here help us understand what level of support would feel most aligned with your goals and capacity right now, allowing us to co-create a sustainable care plan with you.

Thinking about your health goals, which of these statements best describes your desired approach to care over the next 6-12 months? *

Staged Transformation: I'm looking for a focused program to address my most pressing health concerns first.

Foundational Partnership: I'm seeking a long-term, supportive partnership with a care team for consistent oversight.

All-In Transformation: I am ready for a comprehensive, all-inclusive journey and want the highest level of support.

Select the approach you are most drawn to.

To help us guide you to a sustainable care plan, please select the monthly investment you are prepared to make in your health journey. (All our services are HSA/FSA eligible). *

$100 - $300 per month

$300 - $750 per month

$750+ per month

I'd prefer to start with a one-time consultation and discuss ongoing investment later.

This helps us recommend a path that respects your financial capacity.

How We Can Best Partner With You

Our care is a collaborative partnership. These final questions help us understand your perspective on the healing process.

What is the most important outcome you are hoping to achieve by working with our team? *

In your ideal care experience, what does a successful patient-practitioner relationship look like to you? *

Our approach is a collaborative partnership that often involves exploring lifestyle, nutrition, and mindset alongside medical treatments. On a scale of 1-5, how open are you to exploring these areas as part of your care plan? *1 = Not interested, 5 = Very open and ready

Just a Few Final Details

We're almost there! Just a couple of final questions to wrap up.

How did you hear about us? *

I understand that submitting this form is an application for a consultation and does not guarantee an appointment.