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Client information
    1. Today's Date
    2. Referring yourself or someone else SelfSomeone Else
    3. DOB
    4. Sex MaleFemale
    1. Client's Name
    2. Street Address
    3. City
    4. Zip
    5. State
    1. Home Phone Number
    2. Mobile Number
    3. SS#
Referral information
    1. Referred by
    2. Phone Number
    3. Agency Name
    4. Fax
    5. Referring MD name
    6. Phone
    1. Where Did You Hear About HELP?
    2. FacebookGoogleFriendEmailOther Social MediaColleagueOther PatientEmailOther
    3. **For Non-Self-Referring Clients: Chart Notes Are Required Fax To: 858-244-0990.**
    1. Please email me your newsletter - Email:

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Insurance Information Required
    1. Medicare number:
    1. Primary Insurance Name:
    2. ID#:
    3. Group#:
    1. Secondary Insurance Name:
    2. ID#:
    3. Group#:
    1. Primary Insured: SelfSpouseOther

    If Spouse or Other:

  1. Insured Name:
  2. DOB:
  3. SS#:
MD Information
    1. Primary Physician Name:
    2. Phone:
    1. Psychiatrist Name:
    2. Phone:
    1. Psychiatric Medication:

Support System:

Reason for Referral
  1. Reason for Referral:
Requested Place of Service
  1. Requested Place of Service: OfficeHomeFacilityVideo
  2. Email:
  3. Special Needs: ElevatorSightednessHearing IssuesSuicidal IdeationNone