Request Care — New Client Enrollment

Please provide at least a phone number or an email so we can follow up with you.

Complete only if someone other than the client will communicate with us or sign on the client’s behalf. We will independently verify this person’s identity and authority before releasing information or accepting a signature.

Check all that apply. Services are confirmed only after assessment by an RN or qualified supervisor — checking a box here is a request, not an approval.

Select the payment approach you expect to use. This does not commit you and is not a coverage guarantee — our billing team verifies actual coverage separately.

This form is not an electronic signature and does not replace any signed service agreement, which is handled separately.