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
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Month
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Day
Year
Date
Patient Full Name
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DOB
*
Please select a month
January
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Month
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Please select a year
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SSN
Medicaid/Medicare #
Patient Phone Number
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Area Code
Phone Number
Requesting Provider or Social Worker
*
First Name
Last Name
Direct Contact Number
*
-
Area Code
Phone Number
Hospital/Referral Source
48th Street Shelter
All Health Network
Catholic Charaties
CCH Activated Respite Site
CCH Beacon Place
CCH Colliseum
CCH NWS
CCH Protective Action Site
CCH SSHC
Centura-Castle Rock Adventist
Centura-Littleton Adventist
Centura-Other
Centura-Parker Adventist
Centura-Porter
Centura-St. Anthony
Co Community Health Alliance
CO Health Network
Colorado Access
Colorado Coalition (CCH) / Internal
Crossroads Shelter
Delores Project
Denver Health
Denver Health-Eastside Clinic
Denver Health-Hospital
Denver Health-Other
Denver Rescue
Denver Rescue Mission
Denver VA (veteran affairs)
DSOC/Outreach/Streets
Elevation Foot and Ankle
Encompass Rehab
Frisco clinic
Gathering Place
Glenarm
Golden Clinic
HCA-Clinic
HCA-Medical Center of Aurora
HCA-North Suburban Medical Center
HCA-Other
HCA-PSL
HCA-Rose Medical Center
HCA-Sky Ridge Medical Center
HCA-Swedish
Health Solutions
Holy Rosary
Irving Street
Kindred Hospital
Lakewood Rehab
MHCD (Mental Health Center of Denver)
North Range Behavioral Health
Not Listed - Other
People's Clinic Boulder
Powerback Rehab
Rocky Mountain Cares
Rocky Mtn Cancer Center
Roots and Branches boulder
Saint Francis Center
Salvation Army
Samaritan House
SCL-Good Samaritan
SCL-Lutheran Medical Center
SCL-Lutheran Medical Center
SCL-Other
SCL-Platte Valley Medical Center
SCL-St. Joseph
Smith Road Shelter
The Crossing Shelter
UCHealth-Hospital
UCHealth-Other
Urban Peak
Vail Clinic
Vibra Rehab
Villa Manor Care Center
Vivent (Rocky Mountain Cares prior)
West Springs Hospital
Not listed - Other
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
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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
Other
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.
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