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. "We like to save people time and money on the initial consult visit. House Calls Total Wellness provides a full review of the comprehensive information on this intake form as a courtesy. Often we can propose a plan before a House Calls Total Wellness team member gets to your appointment." -House Calls Total Wellness

House Calls Total Wellness is committed to providing safe health standards and complies with state regulations.
House Calls Total Wellness continues to expand online coaching, counseling, & family therapy appointments nationwide.
If you are local to us in or near Montgomery County, Maryland, we are also meeting clients inside or outside the home to maintain a 6 ft physical distance.

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

**House Calls takes payments through Paypal.

SECTION 1

Today's Date:

How did you hear about House Calls Total Wellness?

Friend

Name of Friend:

Relative

Name of Relative:

Your Doctor

Name of Doctor:

Your Therapist

Name of Therapist:

Agency

Name of Agency:

Hospital

Name of Hospital:

Other (Please Explain):

Other:

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

Name of Client:

Client's Age:

Home Number:

Cell Number:

Email Address:

Street Address:

City:

State:

Zip Code:

If Requesting Time, please fill in below

Requested Time:

NOTE: If you are not the client, it is better to meet with you alone the first time if he/she are resistant.

List any comments regarding the location here:

Why did you contact House Calls Total Wellness?

CLIENT'S NEEDS

Please list any comments about Life Transition Categories Here

Elaborate on expectations and what has been done 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:

Referring Party City:

Referring Party State:

Referring Party 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"):

Street Address:

City:

State:

Zip Code:

Home Number:

Cell Number:

Work Number:

Email Address:

Electronic Signature (enter name here):

Payment Agreement:

I agree to all terms of this document.

THE INTAKE BELOW IS OPTIONAL & PROVIDES FOR ADDITIONAL INFORMATION ABOUT CLIENT THAT WILL ASSIST HOUSE CALLS IN ITS EVALUATION OF CLIENT'S NEEDS. IF YOU WISH TO SKIP THIS SECTION, SELECT THE OPTION TO SKIP SECTION 2, BUT WILL PROVIDE SIGNATURE AND SUBMIT.

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

OPTION TO STOP HERE, 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, the remaining questions will populate)

SECTION 2

CLIENT'S FAMILY INFORMATION:

Mother:

Father:

Sister(s):

Brother(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:

Street Address:

City:

State:

Zip Code:

Email Address:

Office Number:

Cell Number:

PSYCHIATRIST:

Name of Psychiatrist:

Street Address

City:

State:

Zip Code:

Email Address:

Office Number:

Cell Number:

SOCIAL WORKER OR PSYCHOLOGIST:

Name of Social Worker or Psychologist:

Street Address:

City:

State:

Zip Code:

Email Address:

Office Number:

Cell Number:

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:

Agree

The fee for an initial consultation is $200 an hour ($45 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.

Hourly contractor rate varies between $100 and 250/hr + travel depending upon the specialist and the services. Additional fees apply if you are requesting the Owner, BETH ALBANEZE, CTRS CPRP ($250 per hour plus travel fee $25 if within Montgomery County).

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

*Credit card and/or any payment used that incurs an added fee will assume the service fee that is extended to House Calls. You have the option to mail a check to our post office box before the last day of the month of that billing cycle to avoid a late fee or service fee. **Cancellation with less than 24 hours notice requires payment of the full fee since the specialist will have reserved their time (that includes no-show).

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.

Agree

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.

Agreement to Pay Bill:

Agree

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.

Agreement to Self-Pay:

Agree

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

Name of Person Paying Bill

Permission Given to House Calls Total Wellness

Agree

Permission is given to House 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.

Email Privacy Statement

For Your Information: In general, email communications are not secure. Please check here for your informed consent to communicate through these channels. If you do not check this, we will assume you will print this Intake (or download the pdf Intake Form to bring with you).

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

Agree

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.

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

Date:

Form Verification *

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Received House Calls Total Wellness Representative: ___________________________________________Date: ___________________________________

Photo of Beth & Debra. Debra will contact you after we receive the intake.
Thank you. ~from Beth