RIDECARE Submission

RIDECARE Submission

Client Name*

Crisis (EOD) or Voluntary

Scheduled trips can be submitted up to five (5) days in advance. Crisis trips are a priority on the day of submission.

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Is client under 18 year of age?*

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Submission Date*

Does client identify as Native American?

CIBD card is not needed.

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Client Information

Date of Birth*

Social Security Number*

XXX-XX-XXXX

Sooner Care Number*

Height*

Weight*

Gender*

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Client Emergency Contact Name

Client Emergency Contact Number

Phone

Referring Information

Client Phone Number

Driver will call client prior to arrival. If client doesn't answer, driver will not stop.

Date of the appointment

What time is the appointment?*

NOTE: For all appointments, dispatchers will notify the submitter of pick-up time, allowing for travel and traffic. Driver can wait 10 minutes.

Range of Time for Arrival?

EX: 9am - 11am, or 1pm to 5pm

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Will the client need a return trip today?

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What time is the return trip?

Referring Entity*

Referring Contact Name*

Referring Contact Phone Number*

Dispatchers will call this number to confirm the details of the transport. If no one answers, transport will be delayed.

Phone

Will this number accept a text?*

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Referring Contact Email*

Submitters will receive an automated email to confirm arrival of this form. Dispatchers will call later to confirm the submitted information.

Pick Up Address and Location*

Address, plus special information (blue door on the left, south of the dumpster, etc)

Destination Information

Destination Facility*

Destination Facility Address*

Destination Facility Contact*

This person will only be contacted if this trip is for in-patient care.

Destination Contact Phone Number*

Phone

Additional Information

Special Precautions or Medical Concerns*

Examples: Suicide/Self Harm, Elopement Risk, ADA Needs, Triggering Elements

History of Violence:

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Aggressive or Violent today?*

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Special Needs/Concerns*

Examples: Recurring trip; client needs help getting to the car; excessive luggage; must ride alone; accompanying child; accompanying adult

Note: Parents must provide appropriate car seat for children.

Is the client medically cleared for transport?*

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IMPORTANT!

We want to thank you for utilizing Ride Care. Our goal is to help you 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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