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Intake Service Form

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

Intake Form - Step Form

  • General Information
  • The Person Needing Assistance
  • Person Contacting House Calls Total Wellness
  • Optional Questions
  • Memorandum of Agreement

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 Total Wellness takes payments through Paypal.

General Information

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

If Requesting Time, please fill in below

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

Client's Needs

(note: some Life Transition and Coordination of Services areas may overlap)

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

NAME AND ADDRESS OF PERSON RESPONSIBLE FOR BILL

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.

 

SECTION 2

CLIENT'S FAMILY INFORMATION:

WHO IS CLIENT'S SUPPORT SYSTEM?

MEDICAL INFORMATION:

MEDICAL DOCTOR:

PSYCHIATRIST:

SOCIAL WORKER OR PSYCHOLOGIST:

Other Information:

RECENT HOSPITALIZATION (if applicable):

MEMORANDUM OF AGREEMENT:

*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).

Agreement to Pay Bill:

Agreement to Self-Pay:

Permission Given to House Calls Total Wellness:

Email Privacy Statement:

Electronic Signature:

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

---------------------------------------------------------------------------------------FOR OFFICE USE-------------------------------------------------------------------------------------

Received House Calls Total Wellness Representative: ___________________________________________Date: ___________________________________

 

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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