Therapy Matters, INC. HCBS Intake Form

Confidential Client Information

Please fill in the form below
We are excited to start your service and we welcome you to our Therapy Matters, Inc. family!

Please follow us on our social media pages and participate in surveys and family events - we are here for you!

If any special accommodations can be made, TMI will go above and beyond to try and accommodate our special families.

Consistent with the legacy of TMI's founder, “Live in the moment and BE the miracle!”
Client's Name:*

First NameMiddle NameLast Name
Client's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number:*

Area CodePhone Number
Cell Phone Number:*

Area CodePhone Number
Do you consent to receiving text messages from Therapy Matters, Inc. regarding scheduling and other important issues? Your privacy is our concern, and we will never sell your information. At any time, you may also opt-out of text messaging; however, it is a great way to stay up to date with your program*

YesNo
Which is the best # to reach you at?*
Can we leave a detailed message on this number?*
Guardian's Name:*

First NameMiddle NameLast Name
Guardian's Relationship*
E-mail:*
Client Birth Date*

MonthDayYear
Client Sex:*

MaleFemale
Primary Care Physician:*
Physician's Phone Number:*

Area CodePhone Number
How did you hear about Therapy Matters?*
What made you choose Therapy Matters?*
In case of Emergency
Contact:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Relationship:*
Which services would you like for us to provide?*

HabilitationRespiteBoth
Do you have a gender preference for the provider?*

FemaleMaleNo preference
Please tell us about our new client (likes, dislikes, etc.)*
Which language is spoken in the home?*

EnglishSpanishOther
Does the client have any allergies?*
What are your major cross streets?*
What days/times would you like to have services?*
Do you have any animals in the house?*

NoneDog(s)Cat(s)Other
DDD Information
Client's SSN
Client's DDD Assist # (if applicable)
Diagnoses (Please list all applicable)*
Parent/Guardian 1's Name:

First NameMiddle NameLast Name
Parent/Guardian 1's Work Number:

Area CodePhone Number
Parent/Guardian 2's Name:

First NameMiddle NameLast Name
Parent/Guardian 2's Work Number:

Area CodePhone Number
DDD Case Manager (if applicable)

First NameLast Name
DDD Case Manager's Phone Number:

Area CodePhone Number
Medical Information Release

I hereby authorize the release of any information, including the diagnosis and the records of any treatments or examinations rendered, to my insurance company or companies, or other healthcare agencies. I also authorize the release of medical records or copies of such and request that they be transferred to Therapy Matters, INC. 1334 E. Chandler Blvd. STE 5A01 Phoenix, AZ 85048
Photo Release: I give permission to Therapy Matters, Inc to photograph my child and use allow to use for social media and marketing.*

AgreeDeny
Please initial that you have read and understand the Medical Information Release*
Signature*

Clear
Date:

MonthDayYear
DateHourMinutesAM/PM Option
HIPAA
(This HIPAA Form is designated for the patient named above.)

I hereby authorize use or disclosure of protected health information about me as described below.

The following person and/or company may receive disclosure of protected health information about the above named patient.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian Name*

First NameLast Name
Electronic Signature Consent - By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. Should you wish to sign a paper form of this intake instead, you may do so. By checking here, you are waiving that right. To change this decision, you must notify Therapy Matters, INC. in writing. Until such notice is received, you are consenting to all documents for future services to be electronically signed as well.*

I consentI do not consent. I will print this paper and sign. Once signed, I will send to Therapy Matters, INC.
Parent or Guardian Signature*

Clear
Date:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Confidential Client Information

In case of Emergency

DDD Information

HIPAA