Referrals: 

We strive for excellence in service to our clients because we really want referrals that are initiated by “word of mouth”.  We also accept direct service requests through our “contact” address on the internet, via regular mail, or by phone/ phone messaging. 

Once a referral is initiated, a phone call and an “in-person” interview will follow. A mutual agreement is reached regarding target goals, access to records or information, assessment and planning, and care coordination and implementation toward mutually identified goals with our clients.

Name:   Phone: E-Mail:
Address:   City: State:

Zip:

  
Referral:  

Specify if other:

How may we help? - In up to 200 words:

How may we contact you?:

        
Other individuals or entities involved in the prospective service (Specify role):

Rating of our services:

   

Please note that we strive for excellence in service & customer satisfaction. We need your input to continue improving and making a difference in the lives of the people we serve.

Important Notices:

1.   Further information such as Date of birth, Date of Injury, Social security, & the like may be sought later as key information to access records for care management & life care planning referrals.

2.   In compliance with HIPAA (Health Insurance Portability & Accountability Act) & PHI (Personal/Private Health Information) protection, Release of information document will need to be signed upon the interview & agreement to render services.

3.   We may have “business associates” working with us on your case: Protection of your privacy rights will be covered under our “Business Associates” contract terms.