Transportation Request

SourcePoint is pleased to coordinate transportation for qualifying clients to and from appropriate medical and social service appointments such as:

▶ Doctor, dentist, lab work, prescribed therapies, dialysis

▶ Counseling/support groups

▶ Adult daycare

▶ Tax or footcare appointments at SourcePoint

▶ Social service appointments related to housing, food insecurity, employment, and utilities

PLEASE NOTE:
● Requests for rides must be submitted 10 days prior to the requested date.

● All volunteer-based transportation is subject to volunteer availability.

● If no volunteer is available, the mobility schedulers will work with SourcePoint clients to find alternate options utilizing public transportation.

Please complete and submit the form below and a mobility scheduler will contact you regarding your transport options. If you require transportation to reoccurring appointments (such as dialysis or adult day care), please call the mobility scheduler directly at 740-913-1888 or your care consultant. Questions may also be directed to mobility@mysourcepoint.org.

Qualifying SourcePoint Client Transport Request Form

Client Information
First Name*
First
Last Name*
Last
Phone*
Email
*for those who wish to receive an email confirmation
Pickup Location Address*
Street Address City ZIP Code
Appointment Information
Date of Transport*
Date Format: MM slash DD slash YYYY
Pick-Up Time*

: HH

MM
Appointment Address*
Street Address City ZIP Code
Appointment Time*

: HH

MM
Estimated Length of Appointment*
Drop-off at Home Time*

: HH

MM
Special Assistance Needs
Please select all options that are applicable:
- Client prefers volunteer to enter the exam room and listen in on physician consultation
- Personal Care Attendant or companion will be riding along
- Client will be receiving sedation (Caregiver is required to ride along)
- Client uses a wheelchair
- Client uses a walker or cane
- Client uses portable oxygen
- Client has vehicle preferences (i.e. - no large trucks, wheelchair accessibility, etc., add to Comments)
- Client might require light assistance
Additional Comments
Consent*
ELECTRONIC COMMUNICATION: In-Home Care Services can receive electronic communications via email, text, and other electronic means. While encryption is used whenever possible, there is a possibility that some communication using these methods is unencrypted, therefore, be advised that any electronic communication we send to you or your emergency contact, those you have provided a release of information, and/or service providers could conceivably be read by a third party if they had the appropriate equipment to see the information in transit. Though this is an unlikely occurrence, it is important you are aware it is possible. Please note that In-Home Care Services does NOT send highly sensitive information such as date of birth via email. By submitting this form, I GIVE consent to allow staff to communicate with you, your emergency contract, and/or service providers using unencrypted electronic communication.
I GIVE consent to allow staff to communicate with me, my emergency contract, and/or service providers using unencrypted electronic communication.
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Transportation Request

Qualifying SourcePoint Client Transport Request Form

Client Information

Appointment Information

Special Assistance Needs

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