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2. 
3. Mobile Integrated Health Program

   Our Program:
   The South County Mobile Integrated Health program is a non-emergency, community-based service with a focus on health promotion, system navigation, and injury prevention.  

   
   

4. 
6. Service Request Form

   Please fill out the required fields and submit.  A participating member will contact you.

   Use this form for residents of Charlestown, South Kingstown and Narragansett

8. First Name*
9. Last Name*
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Town of Residence*
    -- Select One --NarragansettSouth KingstownCharlestown
20. Phone Number

22. An MIH provider will attempt to make contact the individual within 72 hours

26. If you are submitting this form on behalf of someone else

    Please fill out the below section

28. First Name
29. Last Name
31. is the person aware you are submitting this request?
    -- Select One --YesNo
32. Phone Number
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field