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Referrals

If you are interested in referring yourself, or someone else, to EMS Care Group of Texas for services, please fill out the form below and EMS will contact you within 24 hours of your submission. Note that the services listed on this form are provided in Texas. For services in Virginia, please use the EMS of Virginia referral form.

First Name of Person Making Referral

Last Name of Person Making Referral

First Name of Person Needing Services

Last Name of Person Needing Services

Legal Guardian (Name and Contact Information)

Phone Number for Follow Up

Consent for SMS Messages

Please note that by checking this box, you are consenting to an occasional text message notification from EMS of Virginia pertaining to scheduling or services. You may revoke this consent at any time by replying to text messages with 'STOP". Reply HELP for help. Message frequency may vary. Messaging and data rates may apply. Can view our privacy policy at emsofvirginia.com/privacy-policy.

Email for Follow Up

Best Time for Follow-Up

AMPM

Street Address of Person Needing Services

City of Person Needing Services

Zip of Person Needing Services

Medicaid Number

Date of Birth

What services are requested?

Individualized Skills & Socialization / ISS (Texas Only)MentoringPathway Partners Life Skills Texas (Self-Pay)Other

If other, explain in detail below.

Reason for Needing Services

Prefer to talk? Call 469-904-1711 or email info@emsofvirginia.com.