2026 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?
Patient understands that CCH will provide the patient's medical and nursing care during stay.
Patient understands that CCH is not usually able to provide transitional or permanent housing options at discharge unless someone already qualifies for a voucher.
Today's Date

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

MonthDayYear
Date
DOB

MonthDayYear
SSN
Patient Insurance
Medicaid/Medicare #
Patient's Race (please choose most appropriate)
Patient's Ethnicity (please choose most appropriate)
Hospital/Referral Source
MRN at hospital (put N/A if not a hospital referral)
MRN at hospital (put N/A if not a hospital referral)
Hospital account number/FIN/patient control number at hospital (put N/A if not a hospital referral)
Requesting Hospital or Medical Provider or Social Worker

First NameLast Name
Social Worker's Direct Contact Number

Area CodePhone Number
Social Worker's Email Address
Patient Phone or Contact Number To Call Patient

Area CodePhone Number
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.
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)
Does patient use any assistive device(s) for ambulation? (wheelchair, walker)
What assistive devices do they use?
Patient continent and uses toilet without assistance? (Patient requires no help to go to the bathroom)
Patient can take medications independently? (Self manages medications)
Additional information and needs to be filled out for all patients:
Special dietary needs?
What diet is needed/Details:
Service animal or pets?
Details about service animal:
Does client need or use oxygen? (OXYGEN MUST BE COORDINATED BY HOSPITAL PRIOR TO DISCHARGE)
Details for oxygen setup so we can call and confirm (include service provider name, L order, etc.):
Does patient need methadone coordinated for a discharge order? (must be coordinated before arrival)
Does patient have minimum of a one-week supply of ALL medications? (Note: we cannot accept someone without this)
Patient DOB (YYYYMMDD)
Patient DOB (YYYYMMDD)
DOB (YYYYMMDD)
Should be Empty:

CCH Respite Care Program

Current Level of Function and Need

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