Intake Service Form | House Calls Total Wellness

The purpose of this intake form is to prepare for the initial House Calls Total Wellness consultation and save time during the session.

*If you would rather complete the intake form on the phone with one of our team members, you have the option to be interviewed (over the phone). However, a fee may be incurred depending on the length of the interview session. Please let us know if you would rather complete the intake form in this manner.

If you are not comfortable sending in this form online, you may mail or fax the form. Please click HERE to download our printable form

Please complete this online form before the scheduled appointment and click on the Submit button below the form.

General Information

Today's Date

How did you hear about House Calls Total Wellness?

Friend

Name of Friend

Cell Number

Relative

Name of Relative

Cell Number

Your Doctor

Name of Doctor

Phone Number

Your Therapist

Name of Therapist

Phone Number

Agency

Name of Agency

Phone Number

Hospital

Name of Hospital

Phone Number

Other (Please Explain):

Internet Search? Which One?:

Google

Yahoo

Bing

Yelp

AOL

Other:

INFORMATION ABOUT THE PERSON NEEDING ASSISTANCE (THE "CLIENT")

First Name of Client

Last Name of Client

Client's Age:

Home Number

Cell Number

Address Information

Street Address

City

State

Zip Code

Best days for initial consult:

Anytime

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

If Requesting Time, please fill in below

Requested Time:

Where would the client be most comfortable meeting?

Restaurant

Coffee Shop

Library

Relative's Home

Client's Home

School

Work

Telehealth

List any comments regarding the location here:

Why did you contact House Calls Total Wellness?

Client's Needs

Life Transition Categories (Check all that apply):

Accommodations

Advocacy

Case Management

Community Resources

Counseling

Online Counseling

DeClutter/Organization

Discharge Needs

Doctor Referrals

Elderly Issues

Educational

Exposure Therapy

Family Issues

Homecare

Housing Referrals

Medicaid

Recreational

Recovery Coach

Risk Assessment

Social Security

Vocational

Other

If "Other" is selected, please explain

Please list any comments about Life Transition Categories Here

Elaborate on expectations and what has been done in the past that did not work:

What services have been provided in the past that did not work?

PERSON CONTACTING HOUSE CALLS TOTAL WELLNESS ("REFERRING PARTY"):

Referring Party's Name:

Relationship to Client:

Referring Party Home Number:

Referring Party Cell Number:

Referring Party Work Number:

Preferred number to reach you:

Home Phone

Cell Phone

Work Phone

Referring Party Email:

Referring Party Street Address:

Street Address:

City

State

Zip Code

Are you the Authorized Representative to speak on behalf of client?

Yes

Explain

Power of Attorney: Medical

Yes

Power of Attorney: Financial

Yes

Trustee:

Yes

Legal Representative:

Yes

Guardian:

Yes

NAME AND ADDRESS OF PERSON RESPONSIBLE FOR BILL

Is Client or Referring Party responsible for paying House Calls Total Wellness invoices for services to Client?

Client is responsible

Referring Party is responsible

Other

If Other, name of person who will be paying the bill ("Payee"):

Billing Party Street Address:

Street Address:

City

State

Zip Code

Billing Party Home Number:

Billing Party Cell Number:

Billing Party Work Number:

Billing Party Email Address

Electronic Signature (enter name here):

Payment Agreement:

I agree to all terms of this document.

We realize the Intake form is long. At this point, you may skip this section, but it does provide additional information about the client that will assist House Calls in its evaluation of the client's needs.

If you wish to skip this section, select the option to "Skip" Section 2.

Regardless, you will need to hit the Next button, complete the remainder of the form, and provide an electronic signature and click the Submit button.

Select whether you would like to continue with the Intake Form, or stop here and complete the form later with your provider...

OPTION TO SKIP SOME QUESTIONS FOR NOW, AGREE TO MEMORANDUM ITEMS, PROVIDE SIGNATURE, CLICK SUBMIT, AND COMPLETE THE REMAINDER OF THE INTAKE LATER WITH MY PROVIDER

OR OPTION TO COMPLETE THE REMAINDER OF THIS INTAKE FORM'S QUESTIONS NOW (once selected, Section 2 questions will populate)

SECTION 2

CLIENT'S FAMILY INFORMATION:

Mother:

Father:

Brother(s):

Sister(s):

Spouse (marital status):

Children:

Who does client live with:

Relevant Information About Family Dynamics:

WHO IS CLIENT'S SUPPORT SYSTEM?

Financial:

Emotional:

Both:

Strengths of Client:

Limitations of Client:

Client's Weekly Recreational Routine:

MEDICAL INFORMATION:

Relevant Medical Information:

MEDICAL DOCTOR:

Doctor's Name:

Medical Doctor's Street Address:

Street Address:

City

State

Zip Code

Doctor's Email Address:

Doctor's Office Number:

Doctor's Cell Number:

PSYCHIATRIST:

Name of Psychiatrist:

Psychiatrist's Street Address:

Street Address:

City

State

Zip Code

Psychiatrist's Email Address:

Psychiatrist's Office Number:

Psychiatrist's Cell Number:

SOCIAL WORKER OR PSYCHOLOGIST:

Name of Social Worker or Psychologist:

Social Worker or Psychologist's Street Address:

Street Address:

City

State

Zip Code

Social Worker or Psychologist's Email Address:

Social Worker or Psychologist's Office Number:

Social Worker or Psychologist's Cell Number:

Other Information:

List all medications:

RECENT HOSPITALIZATION (if applicable):

Name of hospital(s):

Dates hospitalized:

What behavior necessitated hospitalization?

What has been done in the past in an attempt to help with this issue?

Additional Information:

MEMORANDUM OF AGREEMENT:

The fee for an initial consultation is $250 an hour ($50 for each 15 minutes over the hour) and a $25 travel fee (if within Montgomery County). Outside Montgomery County, IRS business travel mileage will apply.

Agree

The fee for an initial consultation with the owner is $300 an hour ($50 for each 15 minutes over the hour) and a $25 travel fee (if within Montgomery County). Outside Montgomery County, IRS business travel mileage will apply.

Agree

Hourly contractor rate varies between $150-$250 to $100-$300/hr + travel depending upon the specialist & the services that are provided.

Agree

Travel exceeding the Montgomery County radius will be based on current IRS rates per mile.

Agree

Payment is due immediately after the consultation session unless otherwise negotiated with House Calls Total Wellness in advance.

Agree

House Calls takes payment through:

Zelle
Mail: PO Box 776, Olney, MD 20830
Paypal
Credit Card

Cancellation or No Show of a multi hour session will be a 50% charge each hour.

Agree

Cancellation or no-show of a multi-hour appointment with less than 48 hours notice requires payment of the full fee since the specialist will have reserved their time.

Agree

Any phone calls, emails, referrals, and/or advocacy work after the initial consultation, will be billed at an hourly rate (same as above). We will give you advance notice if this is necessary.

Agree

The action plan for services agreed will be emailed to select members of the House Calls Total Wellness team working with this client and one client representative (if not the client).

Agree

If I accept assistance from House Calls Total Wellness, payment is due when services are rendered. Additional fees may apply if House Calls Total Wellness is asked to create multiple action plans, perform any other service and/or discuss the action plan with more than one client representative.

Agree

Agreement to Pay Bill:

I agree to pay for my consultation immediately after services are rendered. If House Calls has not received payment before the end of the month that the service was provided, I understand a late fee will apply until payment is paid in full.

Agree

Agreement to Self-Pay:

I acknowledge - House Calls services provided are private pay and insurance is not an option.

Agree

Name of Person Paying Bill:

Permission Given to House Calls Total Wellness:

Permission is given to House Calls, LLC to communicate with other parties relevant to the client’s rehabilitation goals and objectives. At all times confidentiality will be respected unless there is imminent harm, bodily injury or abuse. We are not a crisis service and defer to the family or relevant community resources to intervene.

Agree

Email Privacy Statement:

I am aware of the risks associated with sending House Calls Total Wellness emails or other channels.

Agree

Please type your electronic signature to give your consent for email correspondence:

Electronic Signature:

I hereby agree to be bound by this agreement and am aware that this electronic signature is enforceable as if it were handwritten. This verifies that I give my written consent to bill me for any of the above related expenditures including legal fees, court costs and collection expenses involved for breach of contract.

Agree

ELECTRONIC SIGNATURE: This signature is binding as if handwritten. Type signature here:

Date

*Electronic or handwritten signature is equally enforceable and indicates you agree with the terms of this agreement.

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Received House Calls Total Wellness Representative: ___________________________________________Date: ___________________________________