Waiting List | Divine Support Services LLC

Additional Agreement Date:

Name

First

Last

Phone Number

Email

Preferred Method of Contact

Phone Call
Email
Text

Date of Birth

Gender

Address

(Street, City, State, ZIP Code)

Types of Services:

Preferred Service Start Date:

When would you like services to begin? (Month, Year)

Additional Comments/Notes:

Anything Else You Would Like Us to Know (This can include specific needs, preferences, or important health information that will help in service planning)

Consent and Agreement

Acknowledgment of Waitlist Status - I understand that this is a waiting list and services will be provided when available

Privacy Notice

Privacy Notice - I understand all of my information will be kept private and used only for purposes related to care services

Follow-up Consent

Consent for Follow-Up - I content to being contacted by Divine Support Services LLC