Mobile Care Unit Intake Form

1

How are you reaching out today?

I’m a patient looking for treatment

I’m referring a patient for treatment

2

Referrer Name* This field is required.

Full name

3

Referrer Role* This field is required.

Healthcare Provider

Employer

Court / Justice Representative

Family / Friend / Other

4

Referrer Organization * This field is required.

5

Referrer Phone* This field is required.

6

Referrer Email* This field is required.

7

Patient Full Name* This field is required.

8

Patient Phone Number* This field is required.By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our HIPAA Notice of Privacy Practices. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.

9

Which state does the individual seeking treatment live in?* This field is required.

Tennessee

Other

11

Is there anything you'd like us to know before we reach out?* This field is required.Please share any relevant details (symptoms, concerns, recent events, discharge plans, court requirements, etc.)

12

How did you hear about us?* This field is required.

13

Source Form (internal)

Mobile Care Unit Intake Form

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Referral Type referral (internal)

Referral Lead

15

Referral Type new patient (internal)

New Patient Lead