Phone Consultation Request
Help in the Home, LLC
Phone: (866) 967-9994
Referral Direct Fax: (888) 611-3340
Email:
Referrals@helpinthehomellc.com
* Required
Client Name
*
Your answer
Client Date of Birth
*
Your answer
Client Gender
*
Male
Female
Client Phone Number/Address/Email
Your answer
Name and Title of Person Completing Form
*
Your answer
Relation to client
Your answer
Phone Number
*
Your answer
Address/Email
Your answer
Psychiatric Diagnosis
DSM Diagnosis (if applicable)
Your answer
Medical Diagnosis
(if applicable)
Your answer
Services Requested
*
Your answer
Is the client medication compliant?
Please answer yes or no and explain
Your answer
Client Physician and Phone Number
Your answer
Client Psychiatrist and Phone Number
Your answer
Client Therapist and Phone Number
Your answer
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
Your answer
Additional Comments
Your answer
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