MHC Help Form
Severity of issue
*
High - Unable to work
Medium - Limiting ability to work
Low - Inconvenience
Name
First Name
Last Name
Email
example@example.com
Program
Please Select
Addiction Services
Case Management
Clinical Development
DUI/ACT
EPIC
IOP
Medical
Outpatient Rural
Outpatient Urban
PACT
Prevention
Rainbow House
Group Home
Support Staff
Admin
Location
Please Select
Big Timber
Columbus
Group Home
Joliet
Lewistown
Main Clinic
Monad 4-Plex
Rainbow House
Red Lodge
Roundup
8th Avenue
Phone Number (Direct # if you have one)
Please enter a valid phone number.
Trouble Shooting Steps Completed (Check All That Are Applicable)
Restart Device
Check Password/Login
Confirm Internet Connection/Signal
Not Applicable
Other
Support Type
File Sharing, Shared Drive, or SharePoint
MyEvolve
Tech Support
Cell Phones
Desk Phones
Printers/MFP
Describe your issue in as much detail as possible. Do not include any patient information.
Bread Crumb of issue location
Severity of issue
High - Unable to work
Medium - Limiting ability to work
Low - Inconvenience
When did this start?
In the last 8 hours
In the last 24 hours
On going for 24 hours+
In detail, explain what is happening
What is your computer ID (sticker on device)
When are you available for a call or remote session if needed?
Equipment Request
For multiple requests, separate with comma
Justification
Manager Email
example@example.com
Maintenance Issue Description
How long has it been an issue
File and/or Picture Upload
Browse Files
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