Telehealth Group Request Form
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Instructions
Please check below if you believe you meet any of the following criteria and provide requested documentation to be considered for telehealth group services. Submissions of this form and required documentation does not guarantee admission into telehealth group services. Check all that apply and provide requested documentation below:
Qualifying Telehealth Criteria
*
No available transportation (Bus system does not go to your location, does not have means of reliable transportation)
No available childcare despite attempts to work with support system or other childcare services
Documented mental health condition
Documented physical health condition
Explanation of Qualifying Telehealth Criteria
Information/Required Documentation
You will be required to meet with one of our Case Managers to determine if you are eligible for Group Telehealth Services. If you are requesting telehealth due to a mental health condition, you must provide a signed letter from a mental health professional stating reason and recommendation to engage in telehealth. If you are requesting telehealth due to a physical health condition, you must provide a signed letter from your attending physician stating reason and recommendation to engage in telehealth.
File Upload
Please use this to upload any letters from your providers or other documentation that supports you needing telehealth group services.
File Upload
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