REFERRAL INFORMATION FORM

Admission Criteria

1.      Must have a primary medical problem and/or custodial care need

2.      Must be physically and psychiatrically stable to receive care in a non-medical respite setting

3.      Must be in need of short-term recuperative care and/or custodial care only

4.      Must be able to perform all activities of daily living (ADLs)

5.      If on Methadone must be in a Methadone Program prior to admission

6.     Must be mentally competent to make decisions for themselves

7.     Must have a primary medical problem that requires support in a non-medical respite setting

 EXCLUSION CRITERIA

1.   Scabies

2.   Quadriplegic needing respiratory support

3.   Active communicable infections C. Diff/MRSA/TB / Covid-19

4.   Dementia, memory loss, cognitive impairment

.  Combative, violent behavior

6.   Acute psychosis/psychotic disorders

7.   Unable to make decisions for themselves

8.   Unable to perform all ADLs and requires assistance with transfers

9.  Other detrimental circumstances that would create a hazard to client or others in the Program

I.   No Gang affiliation

II.  No arsonist or intentional fire starter

 2)    BASIC PERSONAL SERVICES:

(a) Continuous observation and supervision, as needed.

(b) Provide client/resident with bathing and personal items needed for personal care.

(c)   Assistance in meeting necessary medical and dental needs.

(d) Assistance, as needed, with taking prescribed medications in accordance with physician's instructions unless prohibited by law or regulations.

(e) Bedside care for minor temporary illnesses.

The daily rate for basic services is $      275.00      or the SSI/SSP established rate, a government-funded rate of $