Phone Consultation Request
Help in the Home, LLC
Phone: (866) 967-9994
Referral Direct Fax: (888) 611-3340
Email:
Referrals@helpinthehomellc.com
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Client Name
*
Your answer
Client Date of Birth
*
Your answer
Client Gender
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Male
Female
Client Phone Number/Address/Email
Your answer
Name and Title of Person Completing Form
*
Your answer
Relation to client
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Phone Number
*
Your answer
Address/Email
Your answer
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
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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
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Email Address of Referral Source
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Additional Comments
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