top of page

Online Intake Form

The purpose of this intake form is to prepare for the initial Transition House consultation and save time during our initial  session. Please complete the form before the scheduled appointment either online or download here and return the form.

Preferred Method to Contact
Are you the Authorized Representative to Speak on Behalf of Client?
Yes
No

Power of Attorney:

Medical
Yes
No
Financial
Yes
No
Trustee
Yes
No
Authorized Representative
Yes
No
Guardian
Yes
No
I am responsible for paying House Calls $250 intake fee and future appointments.
Yes
No
I Consent to Receive Bill and Pay Online
Yes
No

Information About the Person Needing Assistance (Client)

How Does the Client Prefer to be Reached?
Best Day For Initial Consult

NOTE: If the client will be resistant, it is better to meet with you alone the first time to develop a plan for connecting with the client.

Check most comfortable meeting places:
Categories of Need:
I agree to all terms of this document.
bottom of page