Ride Care Transportation Request

Ride Care Transportation Request - website

Is the Client under an EOD or LMHP Order?*

Secure vehicles have a divider between the front and back seats. Drivers have specialized training in de-escalation techniques and use of restraints.

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Does this trip require a secure vehicle?*

Secure: The client is in a mental health crisis, aggressive, self-harming, elopement risk, etc.

Yes

If the answer is yes to either of the questions above, you are using the wrong form. Please use the Crisis Transportation Form on the website.

Client's date of birth*

Social Security Number*

Example: XXX-XX-XXXX

Is Client under 18 or intellectually disabled?*

Yes

Will parent/guardian travel with client?*

Only one parent/guardian is permitted to ride with the client in the transport vehicle.

Note: Parent/Guardian must be in the same location as client at pick-up. Driver is not permitted to pick up parent/guardian at a different location.

Yes

Client Emergency Contact Name*

Client Emergency Contact Phone Number*

Phone

Height*

Approximate

(Feet and Inches)

Weight*

Approximate

(LBS)

Gender*

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Referring Information

Referring Entity*

Name of the Entity Referring the Client for Transport

Referring Contact Name*

Referring Contact Phone Number*

NOTE: Dispatchers will call this number before assigning a car. If no one answers or returns the call before 6pm, the transport for the following day will not be scheduled.

Phone

Will this phone number accept text messages?*

Select or enter value

OPT-IN for Text Messages*

By checking the box below, I agree to receive SMS messages related to client transportation from Ride Care. You can reply STOP at any time to opt out. For assistance, reply HELP.

Message and data rates may apply. Message frequency may vary.

For more information visit our privacy policy and SMS terms and conditions below:

SMS Terms & Conditions

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Referring Contact Email*

Once this form is submitted, you'll receive an initial confirmation by email. If no one answers this call, the transportation request may be delayed.

Does client have an appointment?*

Yes

Appointment Time*

Note: Submission Form must be received at least 4 hours prior to pick-up time.

**Any forms received after 7pm will be processed the next day at 7am.

Dispatchers will give a pick-up time.

Client Phone Number*

Please notify client the driver will call prior to pick up. If the client does not answer the phone, the driver will not stop.

Phone

Pick Up Address*

Address + Location (Example: sober living, facility name, private residence)

Pick Up Location Instructions*

Example: front entrance, apartment/building number, gate entrance code

Destination Information

Destination Location Name*

Example: sober living, facility name, private residence

Destination Phone Number*

Phone

Destination Location Address*

Must include street address, city, state, and zip code

Destination Location Instructions*

Examples: front entrance, apartment/building number, gate entrance code, contact person name

Return Trip Information

Does client need a return trip on the same day?*

Yes

Return Trip Pick Up Time*

NOTE: Medical appointments are rarely on time—please schedule accordingly. The driver will arrive within a 20-minute window of pick-up time (10 minutes before to 10 minutes after).

The driver cannot wait for extended periods or search for the client. If the client does not answer the phone, the driver will leave after 10 minutes.

Return Trip Pick Up Address*

Must include street address, city, state, and zip code

Return Trip Destination Address*

Must include street address, city, state, and zip code

Special Needs/Concerns*

Please list any important information in this section. This might include a security risk, need for help getting into the car, etc.

IF THE CLIENT REQUIRES AN ACCOMPANYING ADULT, please add the name of the adult here.

RECURRING TRIPS can be scheduled up to five (5) days ahead - please list the dates needed.

Special Precautions or Medical Concerns*

Examples: Suicide/Self Harm, Elopement Risk, ADA Requirements

IMPORTANT!

We want to thank you for utilizing Ride Care. Our goal is to assist your clients with efficient, dependable transportation to their mental health appointments.

As Ride Care continues to grow, so do our processes. Sometimes with a new and innovative system such as Ride Care, hiccups can occur with scheduling. If you experience any type of issue, please call our dispatch center at 800-690-4305. That is the most efficient way of resolving transport issues.

Client Information

Referring Information

Pick Up Information

Destination Information

Return Trip Information

IMPORTANT!