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 Name Middle Name Last Name
Client's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number: *

Area Code Phone Number
Cell Phone Number: *

Area Code Phone 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 *

Yes No
Which is the best # to reach you at? *
Can we leave a detailed message on this number? *
Guardian's Name: *

First Name Middle Name Last Name
Guardian's Relationship *
E-mail: *
Client Birth Date *

Month Day Year
Client Sex: *

Male Female
Primary Care Physician: *
Physician's Phone Number: *

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

First Name Last Name
Phone Number: *

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

Habilitation Respite Both
Do you have a gender preference for the provider? *

Female Male No preference
Please tell us about our new client (likes, dislikes, etc.) *
Which language is spoken in the home? *

English Spanish
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? *

None Dog(s) Cat(s)
DDD Information
Client's SSN
Client's DDD Assist # (if applicable)
Diagnoses (Please list all applicable) *
Parent/Guardian 1's Name:

First Name Middle Name Last Name
Parent/Guardian 1's Work Number:

Area Code Phone Number
Parent/Guardian 2's Name:

First Name Middle Name Last Name
Parent/Guardian 2's Work Number:

Area Code Phone Number
DDD Case Manager (if applicable)

First Name Last Name
DDD Case Manager's Phone Number:

Area Code Phone 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. *

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

Clear
Date:

Month Day Year
Date Hour Minutes AM/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 Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent or Guardian Name *

First Name Last 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 consent I 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:

Month Day Year Hour Minutes AM/PM Option
Should be Empty:

Confidential Client Information

In case of Emergency

DDD Information

HIPAA