Project Cara

Project CARA

Referral Form
Please Note! This referral is not considered received by MAHEC until you receive a confirmation number after clicking the submit button.
Requested Service
Referring Source
Who is submitting this referral?*
If you are referring yourself or a family member, please select "Self/Family Member"
Referring Agency*
Referring Agency Provider or Contact
Referring Agency Phone
Please enter a valid phone number.
Referring Agency Fax
Please enter a valid fax number.
Referring Agency Email
example@example.com
Send a confirmation number to this email?

Yes
Patient Demographics
Name*

Legal First NameLegal Last Name
Middle Initial
Date of Birth*

MonthDayYear
Data
Contact Information
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Send a confirmation number to this email?

Yes
Patient Address
Please check if unhoused

Yes
Street Address*
Apt, suite, unit or floor #
City*
State*
Zip Code*
Input as 5 digits (e.g. 12345)
Additional Details
Patient Living Arrangement*
Is the Patient Pregnant*
What is/are the last substance(s) used?*
Is the patient currently on MOUD?*
Referral Details
Is there any other information that the Project CARA team should know prior to your appointment?
Patient Documents
Please attach any documents that may be helpful.

Cancelof
Attention: Please note that if the patient becomes a MAHEC client, this reason will be included in the referral that is saved to the patient’s chart.
How did you hear about us?
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Project CARA