Social Work Appointment Request

Full Name

Date of Birth

MonthDayYear

Primary Language

Gender

Marital Status

Phone Number

Format: (000) 000-0000.

Type of Phone

Secondary Phone Number

Format: (000) 000-0000.

Type of Phone

Insurance Provider:

Insurance ID #:

Secondary Insurance

Insurance Provider. Please write in "NONE" if you do not have a secondary insurance.

Secondary Insurance ID Number:

E-mail Address

example@example.com

Address *Please note: In-home services are only offered throughout Long Island, Queens and Westchester County

Street Address

Street Address Line 2

CityState

Zip Code

Primary contact person to schedule the first appointment (if other than the client)

First NameLast Name

Relationship:

Is this person also the emergency contact?

Phone Number

Format: (000) 000-0000.

Are there any concerns regarding your living conditions?

Do you have any history or current difficulties with substance abuse?

Were you ever a victim of violence or domestic violence?

Were you ever the perpetrator of violence or domestic violence?

Are there any firearms or weapons in your home?

Are you currently dealing with any legal issues?

Are there any registered sex offenders residing in the home?

Are there any pets in your home?

If you answered yes to any of the questions above, please explain further.

Service being requested

If in-home services are not available, are you open to telehealth services?

What is the reason you are seeking services?

0/250

Available Meeting Times

Name of submitter

First NameLast Name

Relationship to referred individual:

Phone Number of submitter

Format: (000) 000-0000.

I acknowledge and agree that by submitting this form, I acknowledge and understand that I am solely responsible for any charges determined by my insurance carrier, including copayments and deductible charges. I agree to fulfill my financial obligations as outlined by my insurance policy and understand that any outstanding amounts not covered by insurance will be my responsibility to pay. I further acknowledge that the submission of this form does not guarantee insurance coverage or payment, and I am responsible for verifying my coverage with my insurance provider.

Please answer the following questions.

Requested Service(s)