Healthcare Support Home Care, LLC

Client Referral Form

Thank you for considering us for your client's care. Complete the form below and our office will contact you and the prospective client to begin intake. All information is kept confidential and used solely to coordinate care.

Leave this field blank

1Prospective Client

The person who needs care. Attach their facesheet and we'll read the details off it, or type them in below.

Attach a facesheet instead of typingSend the facesheet you already have — PDF or a photo of it — and skip the client fields entirely. We read the name, address, phone, and payer off the sheet. Anything we can't read, our intake team picks up from the attachment.

Full name*

Street address*

City*

State*

ZIP*

Phone number*

Email address(optional)

2Services Requested

Select every service this client is being referred for.

Personal careCompanion careLight housekeepingLaundryRespite

3Preferred Pay Method

How the client expects to pay for care. Choose Unknown if it hasn't been determined yet.

Medicaid EDWPPrivate payLong-term care insuranceUnknown

4Your Information

So we can confirm receipt of this referral and follow up with you directly.

Your name*

Title / role(optional)

Organization / agency(optional)

Your phone number*

Your email address*

5Additional Notes

Anything else we should know — diagnoses, mobility, preferred schedule, discharge date, or the best time to call.

Fields marked * are required.

Questions about a referral? Call (404) 375-7808 or email inquiries@healthcaresupporthc.com

Healthcare Support Home Care, LLC · www.healthcaresupporthc.com