Care Connection

"*" indicates required fields

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.)

I am looking for someone to talk to about my feelings and mood.

I am looking for a way to manager 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 by substance use.

I am looking for medication for substance use.

I am looking for 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.

If you were referred to SalusCare by a medical or legal professional for a specific service, indicate the server if known:

Section 1

First Name*

Middle Name

Last Name*

Suffix

Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

Same as above

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email Address*

Section 2

Date of Birth*

Social Security Number*

Gender at Birth*

Gender Identity*

Other Gender Identity

Ethnicity*

Race*

Primary Language*

Other Language

Do You Require a Translator?

Yes

Special accommodations needed, including ASL interpretation

Food or Medication Allergies

Please type detailed information about any allergies you may have

Section 3

Emergency Contact Full Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Address

Street Address Address Line 2 City State ZIP Code

Legal Guardian Full Name (if any)

Legal Guardian Relationship

Legal Guardian SSN

Legal Guardian Phone

Legal Guardian Contact Address

Street Address Address Line 2 City State ZIP Code

Employment Place

Employment Phone

Section 4

Do you currently have health insurance?

Yes

Primary Insurance Carrier

Primary Policy #

Primary Group #

Secondary Insurance Carrier

Secondary Policy #

Secondary Group #

Are you registered to vote?

Yes

Prefer not to answer

Who referred you to SalusCare?

If other, who?

Referral Health Questionnaire

Treatment Programs

Select a Program

Care Connection

Section 1

Section 2

Section 3

Section 4

Compliment Form

I Would Like To Compliment the Following Saluscare Employee:

Statement of Complaint Form

What steps would you like taken to resolve your concerns?

Should you want to take your complaint to another agency, we have provided contact information for you: