Intake Service Form

*Please note - We do not take insurance (we are private pay).

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.

**House Calls takes payments through Paypal.

(note: some Life Transition and Coordination of Services areas may overlap)
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.
*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).
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.
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.
I acknowledge - House Calls services provided are private pay and insurance is not an option.
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.

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 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.
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Beth and DebraBetter Business BureauPhoto of Beth & Debra. Debra will contact you after we receive the intake.
Thank you. ~from Beth

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