Online Forms
& Applications.
Access our secure online forms for client intake, employment applications, and patient referrals. All submissions are fully encrypted and HIPAA compliant.
Select a Form
Client Intake Form
New clients can securely submit their medical history, contact information, and initial care requests prior to their first consultation.
Employment Application
Join our compassionate team. Submit your resume, references, and professional credentials for open positions listed on our Careers page.
Referral Form
For healthcare providers, social workers, or family members looking to refer a patient to UNHCR services.
Your Data is Secure
All forms submitted through this portal are fully encrypted and adhere strictly to HIPAA guidelines to ensure the utmost privacy and security of your personal and medical information.
How It Works
Choose a Form
Select the form that matches your need — intake, application, or referral.
Submit Securely
Fill out all required fields. Your data is encrypted end-to-end.
We Follow Up
Our care team reviews your submission and contacts you within 24–48 hours.