Refer a Client

refer a client

Atlas Home Health is here to go above and beyond in the delivery of care. You can help our cause by referring a homebound client to us, whether it is you, a family member or a friend.

Use the form below to refer a client to us. All information submitted will be kept strictly confidential.

[contact-form to=’atlasafterhours@gmail.com’ subject=’Refer a Client Submission – atlashh.com’][contact-field label=’Your Name’ type=’name’ required=’1’/][contact-field label=’Your Organization’ type=’text’ required=’1’/][contact-field label=’Your Tel. No.’ type=’text’ required=’1’/][contact-field label=’Clients Last Name’ type=’text’ required=’1’/][contact-field label=’First Name’ type=’text’ required=’1’/][contact-field label=’Tel. No.’ type=’text’ required=’1’/][contact-field label=’Contact Person’ type=’text’ required=’1’/][contact-field label=’Contact Person%26#039;s Tel. No.’ type=’text’ required=’1’/][contact-field label=’Clients Address’ type=’text’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Insurance Information’ type=’select’ options=’Medicare,Medicade,Self Pay’/][contact-field label=’Clients Date Of Birth’ type=’text’/][contact-field label=’Clients Medicare Number’ type=’text’/][contact-field label=’Has the client ever received home health care service in the past?’ type=’radio’ options=’Yes,No’/][contact-field label=’Client lives in a’ type=’select’ options=’House/Apartment,Assisted/Supportive Living,Senior Housing,Group Home,Rented Room,None of The Above’/][contact-field label=’Is the client able to drive a car safely on a regular basis?’ type=’radio’ options=’Yes,No’/][contact-field label=’Does the client use any type of assistive device e.g. cane, walker, wheelchair?’ type=’radio’ options=’Yes,No’/][contact-field label=’Is the client willing to receive home health services?’ type=’radio’ options=’Yes,No’/][/contact-form]