Request for Services
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Parent/Guardian's First and Last Name
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address
*
example@example.com
Client's Name
*
Client's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Age and Gender
*
Client's Primary Care Physician's name and phone number
I am requesting
*
Respite Care (RSP) Services
Habilitation Services (HAB)
Attendant Care (ATC) Services
Occupational Services (OT)
Speech Language Services (SLP)
Physical Therapy (PT)
DDD/ALTCS Application support
Advocacy Services
Community Groups and Activities
Other
If you put "Other", please answer here.
Is this patient a DDD/ALTCS member?
*
Yes
No
I'm not sure
If you are looking for Respite (RSP), Habilitation (HAH) and/or Attendant Care (ATC) services, how many hours of each service a week are you seeking? (i.e. 7 hours of RSP, 10 hours of HAH, and 15 hours of ATC)
*
Do you already have an identified habilitation, respite, and/or attendant care provider(s) for your family member?
*
Yes
No
Maybe
Do you already have an identified therapist for speech, occupational or physical therapy for your family member?
*
Yes
No
Maybe
If you are applying for therapy services (OT, ST, PT), do you plan on using ESA funds?
Yes
No
I don't know
Please list the name(s) of your provider(s) and/or therapist(s) including their email(s) to ensure a quick on-boarding transition.
To help move this process forward, please provide your child’s Support Coordinator’s name, phone number, and email
*
Do you have any specific preferences when requesting a respite, habilitation, or attendant care provider? (We understand each client has specific needs. Please note, the more preferences you identify, the longer it takes to find a provider matching the description.)
Must be a male provider
Must be a female provider
Must be able to transport client
Must be a certain age range
Must speak a language in additional to English
Please describe your answer above if needed.
Please indicate the Member Service Preference Level you determined on your child's planning document (ISP). This indicates how quickly you would need a replacement caregiver if the scheduled caregiver becomes unavailable.
*
Can wait until next scheduled visit by provider
Needs services within two hours
Needs services today
Needs services within 48 hours
I'm not sure
Optional Questions
The following questions are optional. They are designed to give our onboarding team a better understanding of the type of support your family needs. We want to ensure that any provider that we send out to interview is equipped for the level of care that you require.
Is the member in diapers?
Yes
No
Sometimes
Is the member verbal?
Yes
No
Uses a communication device
Does the member utilize medical equiptment?
Yes
No
Is the member mobile?
Yes
No
Sometimes
Does the member have seizures?
Yes
No
Sometimes
Does the member have an aggression or behavioral plan in place?
Yes
No
Branching Out uses SMS text messages and informational emails to share company wide information. Please select YES or NO to agree to receive these communications.By becoming a client of Branching Out, you are automatically opted in. You may opt out of text messages or emails at any time by submitting a written request. Branching Out will never sell or share your information. Thank you!
Yes, I want to receive SMS texts from Branching Out Family Services
No, I do not want to receive SMS texts
Submit
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