2025 CCH Respite Care Program

CCH 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?*

YesNo
Patient understands that CCH will provide the patient's medical and nursing care during stay.*

YesNo
Patient understands that CCH is not able to provide transitional housing options at discharge.*

YesNo
Today's Date *

MonthDayYear
Date
Patient Full Name:*
Gender Identity (Male, Female, FTM, MTF, NB)*
DOB*

MonthDayYear
Medicaid/Medicare #*
SSN
Patient Phone or Contact Number To Call Patient*

Area CodePhone Number
Requesting Provider or Social Worker*

First NameLast Name
Social Worker's Direct Contact Number*

Area CodePhone Number
Hospital/Referral Source*
Direct Contact Email Address*
What is the patient's primary acute medical need?*
What is the patient's ICD 10 code related to their primary acute medical need?*
Is this referral for a contagious or infectious disease need? (COVID 19, Influenza/Flu, Hepatitis A, Tuberculosis, Norovirus, C Diff, RSV, Meningitis, Shigella, Chickenpox/Varicella, Shingles, Measles, Monkeypox, Mumps, Pertussis, Rubella, MRSA, Hepatitis C, VRE or any other virus that can be transmitted human to human). PLEASE ENSURE ACCURACY to protect congregate environments.*
Please list the patient’s acute or chronic medical and psychiatric needs for potential Respite support. Please be as thorough as possible. Omission of information may result in coordination delays.

Unmanaged DiabetesImmunocompromisedObesity > 35M 1 or M 0.5 hold within 90 daysPsychiatric admission within 90 daysETOH Withdrawal ConcernNeeds support/assistance taking medication
If Viral/Infection Concerns, please provide details:
Current Level of Function and Need

If answer is no for any of the below, the patient is likely not eligible.
Patient performs all ADLs 100% independently? (Can feed and dress themselves without assistance)*

YesNo
Does patient use any assistive device(s) for ambulation? (wheelchair, walker)*

YesNo
Details:
Patient continent and uses toilet without assistance? (Patient requires no help to go to the bathroom)*

YesNo
Patient can take medications independently? (Self manages medications)*

YesNo
Additional information and needs to be filled out for all patients:
Special dietary needs?*

YesNo
What diet is needed/Details:
Service animal or pets?*

YesNo
Details:
Does client need or use oxygen? (Note: OXYGEN MUST BE COORDINATED BY HOSPITAL PRIOR TO DISCHARGE)*

YesNo
Details:
Does patient have minimum of a one-week supply of ALL medications? (Note: we cannot accept someone without this)*

YesNo
Should be Empty:

CCH Respite Care Program

Current Level of Function and Need

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