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:

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* 12. Relationship of Alternate Contact Person:

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* 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:

* Was the patient transported to the hospital?

* Submission Information:

* Submitted By:

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* Contact E-mail ([email protected]):

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* Phone Number
Include area code; enter numbers only

Please provide any background information that may be helpful:

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* Has the patient agreed to be referred for assistance?

An attempt will be made to outreach the patient regardless of how this question is answered. Your answer simply helps us know whether the patient is expecting our outreach.
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.