An asterisk (*) indicates a required field.

* 1 . Incident Date: (mm/dd/yyyy)

* 2. Incident Number: (Fire/EMS) (# # - # # # # # # #)

* 3. Patient's First Name:

50 maximum characters (50 remaining)

* 4. Patient's Last Name:

50 maximum characters (50 remaining)

* 5 . DOB: (mm/dd/yyyy)

* 7. Spoken Language:

8. Is Patient Homeless?

* 9. Patient's Address:

Apt No.:

City:

Zip Code:

* 10. Phone Number
Include area code; enter numbers only

11. Name of Alternate Contact Person:

100 maximum characters (100 remaining)

* 12. Relationship of Alternate Contact Person:

100 maximum characters (100 remaining)

* 13. Alternate Phone Number of Alternate Contact Person:
Include area code; enter numbers only

* 14. Living Situation:

* 15. Type of Housing:

* 16. Please Select all Medical Concerns/Needs:

* 18. Please Select All Social \ Mental Health Concerns/Needs:

* 19. Please Select All that Apply:

* 20. Referring Agency:

* Submission Information:

* Submitted By:

100 maximum characters (100 remaining)

* Contact E-mail (xxx@xyz.com):

100 maximum characters (100 remaining)

* Phone Number
Include area code; enter numbers only

Please provide any background information that may be helpful:

8000 maximum characters (8000 remaining)

Note: The information provided herein will be shared with specific Douglas County agencies/departments through My Resource Connection (MyRC) to provide caseworkers and other service providers information including health information, so that they can improve delivery of services to the patient. These agencies/departments will only use and disclose this information in accordance with federal and state confidentiality laws.