Care Navigation Referral

Important Information

Care Navigation requests are initiated within a 48 hour window of submission, a Care Navigator will attempt to contact the family three times (3x) prior to closing the order. Given the 48 hour turnaround, this is not an appropriate avenue for emergent situations, for any emergency situation, call 911 or direct to the nearest emergency department.

What's your name?

What is your email address?

Your email will never be sold or used for marketing, this is purely for communication about your treatment request.

What is your cell number?

Your number will never be sold or used for marketing, this is purely for communication about your treatment request. Only provide a number we have the ability to leave a voicemail message to.

How do you prefer to be contacted by our care navigation team?

Email Phone Call SMS (text message) Any of the above

Briefly describe the situation and concern:

Describe the situation and what you've observed and/or heard, useful additional information includes: symptoms, real world examples involving school/home

I understand that this request form is NOT for emergency situations and/or safety concerns and such emergent situations should be immediately directed to emergency services by dialing 911.

Yes, I understand

I understand that it is my responsibility to obtain all the proper consents and approvals from the parent/guardian (if person is under 18) or the individual (if 18 or older) in order to submit this request form.

Yes, I confirm

Your information will be encrypted.