Pair Team - ECM Assessment Form

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Thank you for taking the time to refer yourself or someone else to the Enhanced Care Management program! Please confirm that you, or the person you're referring, fall into one or more of the following categories:

1. Experiencing homelessness or fleeing domestic violence

2. High emergency department use

3. Severe mental illness

4. Substance abuse disorder

5. Adults Living in the Community and at Risk for LTC Institutionalization
6. Adults Nursing Facility Residents Transitioning to the Community

Once this form is submitted, we will reach out to the phone number provided below within 1 business day to discuss the ECM program, and if desired, provide 1:1 care and support. For any additional questions about us, please contact ECM@pairteam.com

Population of Focus (info above) *

Experiencing Homelessness

High Emergency Department Use

Severe Mental Illness

Substance Abuse Disorder

Adults Living in the Community and at Risk for LTC Institutionalization

Adult Nursing Facility Residents Transitioning to the Community

Required

Name of Person Being Referred (first and last) *

Person's Date of Birth *

YYYY

Person's Contact Number (we will text and call) *

Person's Current Insurance Plan

Person's Current Clinic

Who are you referring? *

Myself

Someone else

Organization you are submitting from *

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