Intake Service Form
The purpose of this intake form is to prepare for the initial HOUSE CALLS consultation and save time during the session.
Please complete this online form before the scheduled appointment and click on the SUBMIT button below the form.
**House Calls takes payments through Paypal.
How did you hear about House Calls?
Information About the Person Needing Assistance (The "Client")
Name of Client:
Best days for initial consult:
If Requesting Time, please fill in below
If you are not the client, it is better to meet with you alone the first time if he/she are resistant.
Where would the client be most comfortable meeting?
List any comments regarding the location here:
Why did you contact House Calls?
Life Transition Categories (Check all that apply):
(note: some Life Transition and Coordination of Services areas may overlap)
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, LLC ("Referring Party"):
Person Contacting House Call's Name (Referring Party):
Relationship to Client:
Referring Party Home Number:
Referring Party Cell Number:
Referring Party Work Number:
Preferred number to reach you:
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?
Power of Attorney: Medical
Power of Attorney: Financial
Name and Address of Person Responsible for Bill
Is Client or Referring Party responsible for paying House Calls invoices for services to Client?
Client is responsible
Referring Party if responsible
If Other, name of person who will be paying the bill ("Payee"):
Electronic Signature (enter name here):
I agree to all terms of this document.
The intake questions below are optional & provide for 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 and complete the questions later with your provider, select the option to skip Section 2, but still provide your signature and click SUBMIT below.
Option to Stop Here, Agree to Memorandum Items, Provide Signature, Click Submit, and Complete the Remainder of the Detailed Intake Questions Later with My Provider
I would like to stop here and complete remaining detailed questions with my provider later
I would like to complete the remainder of the intake's detailed questions now (once selected, the remaining questions will populate)
Client's Family Information:
Spouse (marital status):
Who does client live with:
Relevant Information About Family Dynamics:
Who is Client's Support System?
Strengths of Client:
Limitations of Client:
Client's Weekly Recreational Routine:
Relevant Medical Information
Name of Psychiatrist:
Social Worker or Psychologist:
Name of Social Worker or Psychologist:
List all medications:
Recent Hospitalization (if applicable):
Name of hospital(s):
What behavior necessitated hospitalization?
What has been done in the past in an attempt to help with this issue?
MEMORANDUM OF AGREEMENT:
The fee for an initial consultation is $175 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.
Additional fees apply if you are requesting the Owner, BETH ALBANEZE, CTRS CPRP ($225 per hour plus travel fee $25 if within Montgomery County).
Travel exceeding the Montgomery County radius will be based on current IRS rates per mile.
Payment is due immediately after the consultation session unless otherwise negotiated with House Calls, LLC in advance.
*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.
A Terms of Agreement form will be completed by House Calls and remitted to the person paying the bill for signature before services are rendered.
The action plan for services agreed will be emailed to select members of the House Calls team working with this client and one client representative (if not the client).
Additional fees may apply if House Calls 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:
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.
Type Name of Person Paying Bill
Signature of Person Paying the Bill
Permission Given to House Calls, LLC
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.
I am aware of the risks associated with sending House Calls emails or other channels.
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.
Type Name of Person Paying the Bill
ELECTRONIC SIGNATURE: This signature is binding as if handwritten. Sign signature here.
Please verify that you are human
------------------------ Office Use Only ------------------------
Received House Calls Representative (Client , please leave this field blank):
Date Received (Client, please leave this field blank):
---------------------------------------- Office Use Only --------------------------------------------
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm