Ride the Road to Recovery Transportation Request Form
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Mission
Our mission is to provide secure, safe and timely transportation to Surry County residents who require assistance in meeting and exceeding a healthier future. After submitting your Ride request, staff will contact you with any concerns and to confirm that we received your request. If you have questions please contact Surry County Transportation Staff at 336-401-8266.
Service Alerts
Transportation Staff are being required to update rider information and records. Please note that you may be asked to submit additional information to ensure we can serve you best. Also please note that requests are subject to be denied due to various limitations. Various limitations include, but are not limited to service capacity.
Request Your Transportation Here!
Please take a moment to fill out the form.
Your name
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First Name
Last Name
What is your date of birth?
*
-
Month
-
Day
Year
Date Picker Icon
Your email adress
example@example.com
Your phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of communication
*
Call
Text
Your current address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you filling this request form out on behalf of yourself?
Yes
No
If, no. Please provide your name and relationship to the individual.
First time filling out this specific Ride the Road to Recovery Transportation request form?
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Yes
No
Has any of your personal information changed since your last transportation request?
Yes
No
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Required Demographic and Other Information
What is your age?
*
What is your gender?
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Female
Male
Prefer Not to Say
What is your ethnic origin?
*
American-Indian
Asian
Black
Native Hawaiian or Other Pacific Islander
White
Hispanic
Some Other Race/Multiple
Prefer Not to Say
Are you a Veteran?
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Yes
No
Would you like to be connected to Veteran Services?
Yes
No
Are you a Surry County resident?
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Yes
No
An emergency contact is a person designated to be contacted in case of an accident, illness, or other crisis where the individual is unable to communicate for themselves. This person is usually someone trusted, like a family member or close friend, who can provide assistance, information, or make decisions on the individual's behalf.
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By checking his box I do hereby authorize the staff and volunteers representing the Surry County Office of Substance Abuse Recovery (SCOSAR) to release and disclose my status as a participant of the program, my current location, and any health information related to an emergency with my emergency contact(s) listed below in the event that I am incapacitated or otherwise unable to make the contact(s) on my own behalf.
What Surry County Office of Substance Abuse Recovery services you are using? (past or present)
Recovery to Work
Surry Transition Project
Accountability and Recovery Court
Post Overdose Response Team (PORT), Intervention Team
Other
Have you been released from a Detention Center or Prison within the last 30 days?
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Yes
No
Are you on Probation or Parole?
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Yes
No
If yes, who is your Probation Officer?
Are you actively participating in Accountability and Recovery Court?
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Yes
No
Has Court ordered for you to participate or attend treatment?
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Yes
No
Do you have Health Insurance?
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Yes
No
If yes, type of Health Insurance
Employer or Private/Commercial Insurance
Military or Veteran's Insurance
Insurance Exchange
Medicaid
Medicare
Uninsured
Unknown
Other
Do you have transportation available to you?
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Yes
No
Physical conditions/limitations or allergies that we need to be aware of?
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Yes
No
If yes, explain.
Current Treatment you are participating in:
Bethany Medical
Daymark
Health & Nutrition Center
Hugh Chatham Family Medicine
Northern Regional Hospital
ICGH (Intergrated Care of Greater Hickory)
Phoenix
Surry Rural Health
TASC
Welcome MAT
Other
Current Recovery Support you are participating in:
Community (Probation, Community Service, Court)
Employment
Education
Self Help
Other
Current Primary Healthcare you are participating in:
Bethany Medical
Grace Clinic
Health and Nutrition Center
Hugh Chatham Family Medicine
Pharmacy (medication fulfillment)
Surry Medical Ministries
Surry Rural Health
Other
Current Other services you are participating in:
Clothing from thrift stores or other outreach programs
Department of Social Services (Child visitations, Child Support Services, Financial assistance)
Food Pantries
Government Assistance: Phone, food Stamps, Housing, etc.
Homeless Supplies
Identification
Naloxone
Other
Are there any listed services above that you would like to participate in or have access to?
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Yes
No
If so, explain which services.
Other information that we need to know?
What Else Do We Need to Know to Make Sure We Can Pick You Up?
Upon your first pick up there will be additional information gathered. Along with a number of documents for you to sign such as a release of information for the services indicated, Emergency Contact signature form, Informed Consent, and more.
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I agree
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Transportation Request Required Information
Please Provide the Following Information.
Is you pick up address the same as your current address?
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Yes
No
Pick up address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this a one way trip?
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One Way Trip
Round Trip
Transportation destination
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Apogee
Bethany Medical
Daymark
Children Center
Employment Related Services - Recovery to Work
Grace Clinic
Hope Valley - Dobson
Hope Valley - Pilot Mountain
ICGH (Dobson)
Journeys Counseling
Phoenix Counseling - Dobson
Pharmacy - upon request DRIVE THRU ONLY (exceptions are Wally's and Gates Pharmacies)
Serenity Counseling
Surry Community College
Surry County Accountability and Recovery Court (ARC)
Surry County Court
Surry County Department of Social Services
Surry County Health and Nutrition Center
Surry County Office of Substance Abuse Recovery
Surry County Probation
Surry County TASC
Surry Medical Ministries
Surry Rural Health
Unique Background Solutions
Welcome MAT
Other
If other, provide destination.
*
Is this your first appointment at the service provider?
*
Yes
No
Trip Details
Please be as accurate as possible about the details of your trip.
Date and Time of appointment
*
Expected duration of appointment
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Please Select
30 Minutes
1 Hour
1.5 Hours
2.0 Hours
2.5 Hours
3.0 Hours
4.0 Hours
4.5 Hours
Other
How Long will Your Appointment Take?
Is this a recurring appointment?
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Yes
No
If this is a reoccurring appointment, choose the days you need transportation.
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
I was referred by:
*
Please Select
Accountability and Recovery Court
Church / Religious Organization
Daymark
Department of Social Services
EMS - Post Overdose Response Team (PORT)
Family / Friend
Health and Nutrition Center
Hospital
Probation
Recovery to Work
Surry Transition Project
TASC
I Found the Service Myself
Other
Other information we need to know?
Include Specific Directions to Your Pick Up Location
I agree to the terms and conditions stated on this webpage. I also understand for routing and scheduling, submissions must be received two business days prior to the actual appointment date needed. I also understand that weekends (Saturday and Sunday) to do not count in the two day requirement. Meaning requests submitted on Thursday after 12pm (noon) for Monday the following week will not be accepted.
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I understand the two business day requirement.
I understand that Ride to Recovery is a no cost Rideshare Transportation Program. Rideshare programs like this, connect multiple people in one vehicle that travel together to the same or similar destination. While rider privacy and confidentiality are very important to the Ride the Road to Recovery Program and Staff, our program cannot assure anonymity and confidentiality. Please contact Ride the Road to Recovery Staff if you have concerns.
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I Understand Ride the Road to Recovery is a Ride Share Program
Reminder!!!
If you chose Reoccurring Appointments please make sure to indicate the days you will need transportation assistance.
What Happens Next?
After submitting your Ride request, staff will contact you with any concerns and to confirm that we received your request. Your transportation request is not scheduled until you receive official confirmation from Ride to Recovery Staff.
What to Expect
Our staff strives to meet and exceed appointment requests, please do your part to be ready 1 hour prior to scheduled arrival times. We also take pride in a clean, safe environment for your comfort, we request that only water bottles are allowed during travel to and from destinations.
Important
After submitting your request, an automatic email receipt should be received within ten minutes from a no-reply email address. Please check your email account and/or spam folder for this email. If you do not see a receipt, email your submission was not received. Call our office at 336-401-8266 for assistance.
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