Formas disponibles en EspaƱol

If you are in crisis STOP.  Call 911 or our Emergency Services Department at 239-275-4242.

How can SalusCare Help? (Please select all the below statements that apply to you.)
  Please select or leave blank...  
I am looking for someone to talk to about my feelings and mood.  
I am looking for a way to manage my anger.  
I am looking for medication for mental health.  
I am looking for family counseling.  
I am looking for marital counseling.  
For my child, I am looking for ways to manage mood and behavior.  
I am looking for help with working with my child's school.  
I am looking for resources for myself/child/family such as food, clothing, housing, employment, accessing benefits, child activities.  
I am looking for a way to manage my substance use.  
I am looking for medication for substance use.  
I am looking for a way to detox from drugs and/or alcohol.  
I am looking for a sober living facility.  
My child is using illegal substances.  
I am not sure. I would like to talk to someone about my needs.  
I was refered to SalusCare by medical or legal professional for a specific service.
Please indicate service if known:
 
SECTION 1.
If unsure please leave blank
SALUSCARE, INC. DEMOGRAPHIC FORM
Last Name:
First:
Middle:
Suffix:
  Preferred Name:
Address:
City:
State:
ZIP:
County:
Mailing Address:  ( SAME AS ABOVE) City:
State:
ZIP:
County:
Home Phone: ( PREFERRED) Work Phone: ( PREFERRED)
Cell Phone: ( PREFERRED)
E-MAIL Address:
How can we best contact you:
Other way(s) of contacting you:
SECTION 2.
DOB: (mm/dd/yyyy)

SSN:
Gender at Birth:
Gender Identity:
Other Gender Identity:
Ethnicity:

Race:
Primary Language:
Other Language:
Do you require a translator?:
Yes No
Please list any special accommodations needed, including ASL interpretation:

 
SECTION 3.
Please type DETAILED information about allergies to food or medications (If any):

Please describe any allergic or unpleasant reactions to medications:
Emergency Contact Full Name:

Emergency Contact Relationship:

Emergency Contact Phone #:

Emergency Contact Address:

City/State/ZIP:

Legal Guardian Full Name (If Any):

Legal Guardian Relationship:

Legal Guardian SSN:

Legal Guardian DOB: (mm/dd/yyyy)

Legal Guardian Contact Address:

City/State/ZIP:

Guardian Phone #:

Employment Place:

Employment Phone #:

SECTION 4.
Do you currently have Health Insurance?:
Primary Insurance Carrier:

Policy #:
Group #:
  Secondary Insurance Carrier:

Policy #:
Group #:
Are you registered to Vote?:

Who referred you to SalusCare:

Other:


Please bring any relevant documentation.