Pair Team - ECM Assessment Form 
Thank you for taking the time to refer someone to our Enhanced Care Management program! Please confirm that the person you're referring falls into one or more of the following categories:

1. Homelessness
  • No stable housing
  • At risk of homelessness
  • Fleeing domestic violence
2. High emergency department use
3. Severe mental illness
4. Substance abuse disorder

If they fall into one or more of the categories above, please provide some basic information on the person you are submitting below.

Once this form is submitted, we will reach out to them within the next 24 business hours to assess program eligibility and provide 1:1 care support. For any additional questions about us, please contact

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Person's First Name *
Person's Last Name *
Person's Date of Birth *
Person's Contact # *
Person's Current Insurance Plan
Person's Current Clinic
How Can We Help?
Your Name
Your Contact Info
Organization you are submitting from *
By checking this box, you agree the individual being submitted has consented to sharing their information for engagement and treatment purposes
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