�

�

Referrals:�

We strive for excellence in service to our clients because we really want referrals that are initiated by �word of mouth�.� We also accept direct service requests through our �contact� address on the internet, via regular mail, or by phone/ phone messaging.�

Once a referral is initiated, a phone call and an �in-person� interview will follow. A mutual agreement is reached regarding target goals, access to records or information, assessment and planning, and care coordination and implementation toward mutually identified goals with our clients.

Name: � Phone: E-Mail:
Address: � City: State:

Zip:

 �
Referral: �

Specify if other:

How may we help? - In up to 200 words:

How may we contact you?:

 � � � �
Other individuals or entities involved in the prospective service (Specify role):

Rating of our services:

� �

Please note that we strive for excellence in service & customer satisfaction. We need your input to continue improving and making a difference in the lives of the people we serve.

Important Notices:

1.�� Further information such as Date of birth, Date of Injury, Social security, & the like may be sought later as key information to access records for care management & life care planning referrals.

2.�� In compliance with HIPAA (Health Insurance Portability & Accountability Act) & PHI (Personal/Private Health Information) protection, Release of information document will need to be signed upon the interview & agreement to render services.

3.�� We may have �business associates� working with us on your case: Protection of your privacy rights will be covered under our �Business Associates� contract terms.

 �
This form of hublot replica is the top companion to the pro diver, extremely sought following through the farsighted look at lovers. The water-resistant methods of tag heuer replica are enhancing because the launch. The diving depth begins through the first 100m, 200m to 300m, completely proved its achievement in water-resistant purpose of wristwatches. The new rolex replica sale metal style carries a metal look at situation measured 40mm at diameter. The durability and higher drinking water resistance ensure it is far better resist the replica watches sale on the seawater. The sole rotating bezel is crafted from scratched dark ceramics. The internal replica watches sale on the graduation of scale is coated with platinum. The hour, moment and 2nd arms along with the markers are plated with Chromalight luminescent materials, producing the time rolex replica sale readable at any situation.