Ride Care Transportation Request

TRIPS CAN BE SCHEDULED UP TO FIVE (5) DAYS IN ADVANCE; MUST BE SUBMITTED BY 7PM ON FRIDAY FOR A MONDAY TRIP.

Day of trip submissions are subject to availability.

Submission Date

mm/dd/yyyy

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.

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 Information

Client Name

Client's date of birth

mm/dd/yyyy

Social Security Number

Example: XXX-XX-XXXX

Is Client under 18 or intellectually disabled?

Yes

Height

Approximate

(Feet and Inches)

Weight

Approximate

(LBS)

Gender

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?

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

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.

Pick Up Information

Pick Up Date

mm/dd/yyyy

Does client have an appointment?

Yes

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

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.

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