Home Today Intake Paperwork
Email *
WELCOME!

Thank you for choosing Home Today Consulting Services for your home safety needs. To start this process, we need to confirm your contact information and understand your reasons for requesting service. We will not share information unless OK’d by you. We follow strict confidentiality / HIPPA rules.

The information required to initiate services consists of the following:

Section 1: Client Contact Information Form

Section 2: Fee/Payment Information

Section 3: Your story

Section 4: Service Agreement 

Note: You will also need to sign a separate client consent document.

Tips to get the most out of your therapy visits:

1. These are your visits. Be sure to share your goals and/or concerns with your therapist.

2. Communication helps the results of therapy. Involve us with your friends and family to create a team of support.

3. Please complete these intake documents as much as possible; otherwise missing information may delay the start of services.

Name *
Home Address *
Billing Address (if same write "Same") *
Preferred Phone Number *
Email Address *
What is your preferred method of contact? *
Emergency Contact Name and Relationship *
Emergency Contact Phone Number *
Name of Responsible Party for Payment/Relationship *
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