Activated Respite Care Bridge Housing Program

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? *

Yes No
Patient understands that CCH will provide the patient's medical and nursing care during stay. *

Yes No
Patient understands that CCH is not able to provide transitional housing options at discharge. *

Yes No
Today's Date *

Month Day Year
Date
Patient Full Name *
DOB *

Month Day Year
SSN
Medicaid/Medicare #
Patient Phone Number

Area Code Phone Number
Requesting Provider or Social Worker *

First Name Last Name
Direct Contact Number *

Area Code Phone Number
Hospital/Referral Source
Direct Contact Email Address *
Is this facility in Denver? *

Yes No
Is this a COVID-19 related referral? *

Yes No
Has Patient been tested yet?

Yes No
Date of Test

Month Day Year
Date
Location of Test
Result

Positive Negative Pending
Has patient already been vaccinated?

Yes No
Current symptoms

New Fever New Cough New Shortness of Breath New onset loss of taste and/or smell
Please list the patient's acute or chronic medical and psychiatric needs for potential Respite support (please select all that apply)

Above the age of 60 Unmanaged Diabetes Psychiatric Diagnoses Immunocompromised Chronic Heart Disease Psychiatric Admit w/in 90 days Obesity (BMI > 30) ETOH Withdrawal Concern Viral/Infection Concern or Isolation Need Respiratory Illness Mobility Concerns
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) *

Yes No
Patient can take medications independently? (Manages all medications without help) *

Yes No
Patient alert & oriented x 3? (Not confused, understands what is going on) *

Yes No
Patient continent and uses toilet without assistance? (Patient requires no help to go to the bathroom) *

Yes No
Additional information and needs to be filled out for all patients:
Special dietary needs? *

Yes No
What diet is needed/Details:
Service animal or pets? *

Yes No
Details:
Can patient walk up/down a flight of stairs without assistance? *

Yes No
Details:
Does patient use any assistive device(s) for ambulation? (wheelchair, walker) *

Yes No
Details:
Hospital/clinic referrals
Does patient have minimum of 48-hour supply of ALL medications? (Note: we cannot accept someone without this) *

Yes No
Does client need or use oxygen? (Note: Oxygen needs to be coordinated by hospital before discharge) *

Yes No
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.) *

Yes No
Please upload copy of last Physician Progress Note.

Browse Files

Cancel of
Should be Empty:

CCH Activated Respite Care Program

Current Level of Function and Need

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

Hospital/clinic referrals