• CCH Activated Respite Care Program

    All referrals must be approved by Colorado Coalition for the Homeless staff prior to intake
  • Patient agrees to have their information shared to coordinate services?*
  • Patient understands that CCH will provide the patient's medical and nursing care during stay.*
  • Patient understands that CCH is not able to provide transitional housing options at discharge.*
  • Today's Date *
     - -
    2 digit month, 2 digit day, 4 digit year
  • SSN
  •  -
  •  -
  • Direct Contact Email Address*
  • Is this facility in Denver?*
  • Is this a COVID-19 related referral?*
  • Has Patient been tested yet?
  • Date of Test
     - -
    2 digit month, 2 digit day, 4 digit year
  • Result
  • Has patient already been vaccinated?
  • Current symptoms
  • Please list the patient's acute or chronic medical and psychiatric needs for potential Respite support (please select all that apply)

  • Current Level of Function and Need

    If answer is no for any of the below, the patient is not eligible.
  • Patient performs all ADLs 100% independently? (Can feed and dress themselves without assistance)*
  • Patient can take medications independently? (Manages all medications without help)*
  • Patient alert & oriented x 3? (Not confused, understands what is going on)*
  • Patient continent and uses toilet without assistance? (Patient requires no help to go to the bathroom)*

  • Additional information and needs to be filled out for all patients:

  • Special dietary needs?*
  • Service animal or pets?*
  • Can patient walk up/down a flight of stairs without assistance?*
  • Does patient use any assistive device(s) for ambulation? (wheelchair, walker)*

  • Hospital/clinic referrals

  • Does patient have minimum of 48-hour supply of ALL medications? (Note: we cannot accept someone without this)*
  • Does client need or use oxygen? (Note: Oxygen needs to be coordinated by hospital before discharge)*
  • Does client need wound care? (Note: If yes, send wound care instructions and pictures if able. Patient must be able to do own wound care or wound must be manageable with minimal nursing support.)*
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