Social Work Appointment Request

Full Name*

Date of Birth*

MonthDayYear

Primary Language*

Gender *

Marital Status*

Phone Number*

Type of Phone

Secondary Phone Number

Type of Phone

Insurance Provider:*

Insurance ID #:*

Secondary Insurance *if applicable

Insurance Provider

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

Are there any concerns regarding your living conditions?*

YesNoUnknown

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

YesNoUnknown

Were you ever a victim of violence or domestic violence?*

YesNoUnknown

Were you ever the perpetrator of violence or domestic violence?*

YesNoUnknown

Are there any firearms or weapons in your home?*

YesNoUnknown

Are you currently dealing with any legal issues?*

YesNoUnknown

Are there any registered sex offenders residing in the home?*

YesNoUnknown

Are there any pets in your home?*

YesNoUnknown

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

Service being requested*

Telehealth Counseling ServicesIn-Home Counseling Services

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

YesNoUnknown

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

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.

I acknowledge and agree with the above statement regarding financial and insurance obligations.

Please answer the following questions.

Requested Service(s)