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To apply for WMEC services or make a referral for someone else, please complete all sections of the secure form below. 

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Professional Referrals – Online Intake Singe Page Form

Consumer’s Personal Information

Referral Source

Consumer’s Medical Information

Emergency Contact 1

Emergency Contact 2

Access to Technology

Does the consumer have technology such as a tablet, lap top, smart phone, etc., that could be used to conduct a virtual visit if needed? *
If the consumer does not have or cannot personally use technology needed to conduct a virtual visit, does the consumer have any informal supports that may be able to assist? *

COVID-19 Screening

Has the consumer or anyone in the home been diagnosed with COVID-19 or currently awaiting results from a COVID-19 test? *
Has the consumer or anyone in the home had a fever, cough, shortness or breath, experience loss of senses of taste or smell, or had a sore throat in the last 14 days? *
Has the consumer or anyone in the home traveled outside of Massachusetts in the last 14 days? *

Additional Information