1:1 Consumer Specialing Service Request Form

If you would rather print out the fact sheet and mail it in, click here to download the PDF version.

Please select the office to which you want to send this form:

Service Location:
Street Address:

City, state, zip:
Unit/department/bldg:
Contact:
Phone:
Confirm shifts with:
Phone:	Day: Night:
Contact at service location:
Phone:	Day: Night:
Diagnosis:
Rx:
Diagnosis code:
Reason for specialing:

Billing Information

Agency responsible for payment:
Office to bill:
Billing contact:
Address:

City, state, zip:
Phone:	Fax:
Authorization #:
Credit limit:
Authorized through:	//
Ordering physician:
Phone:

Additional Consumer Information

Consumer history:
Target behaviors:
TX plan and/or behavior programs:
Suggested activities:
Special skills required:
Brief description of service location (setting, type of consumers, rules/guideline, etc.):
Complete the transportation directions in as much detail as possible by car and public transportation, if applicable. The directions you give are the directions we will give our staff to get to your program. Please give an approximation of miles, landmarks, colors of the building or house, major highways and bus numbers. Please use additional paper if necessary. Directions by Car: (ALSO, please include landmarks, building description and entrance procedures. Example: "Center is located in a brick building next to a Starbucks Coffee—ARBOR Staff must sign-in at front desk." Is parking available? Yes No Where? Directions by MBTA (bus and/or subway):
Fact Sheet completed by:	Name: Title: Phone: