In-Home Service Form

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In-Home Service Form

In-Home Service FormAdmin2022-05-26T15:17:25+00:00

Client Name

Sex

Client Phone Number *

Client Mobile Phone Number

Client Email *

Client Address *

Street Address Line 2 *

City *

State/Province *

ZIP / Postal Code *

Country

Minnesota County of Service (If the client's county of residence is not listed, we do not offer this service in their county) *

Client Date of Birth *

Does This Client Have a Legal Guardian? *

Legal Guardian Name *

Legal Guardian Email Address *

Legal Guardian Phone Number *

Insurance Company *

Eligibility for this State-funded programming requires an active form of Minnesota Medical Assistance. This can be Straight MA or a PMAP plan through an insurance carrier. Before KESMA Flame Lily Family Services can begin providing services to any client, we MUST have correct insurance information and an active insurance plan. This includes the PMAP insurance provider if there is one, member ID, group number, and the MA# or PMI#. Straight MA will only need their 8-digit MA number.

Group Number *

ID Number *

PMI# *

Therapist Gender Preference *

Previous/Current Diagnosis (if applicable)

Referrer Name

Referrer Email *

Referrer Phone Number *

Is the client willing to see their clinician via telehealth due to the current pandemic?YesNo, in-person appointments only

Any additional information to help find a good match for a practitioner please write below:

How did you hear about us? *

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Other

Are you also interested in scheduling a medication management appointment?YesNo

As soon as we receive a referral, KESMA Flame Lily Staff will review it and check for complete information and insurance eligibility. Incomplete information will add time to processing. Referrals with inactive insurance will be passed back to the Referring Party and they are invited to re-refer once MA Plan is active. In cases where MA is applied for but not yet approved, documentation of application will be required to consider scheduling.