CLASS HOME CARE LLC
Compassionate In-Home Care
📍 451 W Cottage Grove Rd, PO BOX 51, Cottage Grove, WI 53527
📞 (608) 361-8917 | 🌐 www.classhomecare.net

CLTS Intake Form

1. Child’s Information













2. Parent/Guardian Information













3. Requested Services










4. Preferred Schedule







5. Additional Considerations



6. Referral Information







7. Consent

I confirm that the information provided is accurate. I give Class Home Care LLC permission to contact me and collaborate with my child’s CLTS case manager.