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Phone Consultation Request
Help in the Home, LLC
Phone: (866) 967-9994
Referral Direct Fax: (888) 611-3340
Email:
Referrals@helpinthehomellc.com
You will receive a response within 1 business day.
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Client First Name
*
Your answer
Client Last Name
*
Your answer
Client Date of Birth
*
Your answer
Client Gender
*
Male
Female
Non-Binary
Other:
Client Phone Number
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Client Address Line 1
Your answer
Client Address Line 2
Your answer
Client City
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Client State
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Client Zip Code
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Client Email
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First Name of Person Completing Form
*
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Last Name of Person Completing Form
*
Your answer
Title of Person Completing Form
*
Your answer
Relation to client
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Phone Number
*
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Email
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Address
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Psychiatric Diagnosis
DSM Diagnosis (if applicable)
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Medical Diagnosis
(if applicable)
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Services Requested
*
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Is the client medication compliant?
Please answer yes or no and explain
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Client Physician and Phone Number
Your answer
Client Psychiatrist and Phone Number
Your answer
Client Therapist and Phone Number
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List Funding Source and Budget
Insurance Not Accepted
Your answer
What is the client's daily and weekly activity?
Your answer
How did you find out about us?
*
Web search
Conference
E-newsletter
Discharge planner/nurse
Personal Referral
Therapist
Direct mail solicitation
Psychiatrist
Treatment consultant
Social Worker
Other:
Name of Referral Source
*
Your answer
Relation of Referral Source to Client
Your answer
Phone Number of Referral Source
Your answer
Email Address of Referral Source
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Additional Comments
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