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Recuperative Care Referral Form

Recuperative Care Referral Form

1) I am submitting a referral for... *

Myself
A family member or friend
My patient
My client

2) Basic Information about Individual being Referred

Name: *

First

Last

Date of Birth (DOB): *

Gender: *

Phone Number: *

Email: *

Communication Preference: *

Phone
Email

Individuals Current Location: *

3) Medical Information

Primary Diagnosis: *

Secondary Diagnosis:

Current Medications: *

4) Reason for Referral: *

Please describe the individual’s current physical/medical condition and why they need recuperative care services. Indicate the preferred date the individual would come to recuperative care:

individual Is the

5) Care Requirements: *

Is the individual going to a Skilled Nursing Facility (SNF) before coming to COTS Recuperative Care? (Yes/No). If ‘yes’, provide the name of SNF and estimated length of stay at SNF.

Is the individual oriented to date and time? *

Yes
No

Is the individual able to make decisions independently? *

Yes
No

Is the individual able to communicate their needs? *

Yes
No

Is the individual free of communicable diseases? *

Yes
No
Unsure

e.g., COVID, MRSA, ETC.

Is the individual having uncontrollable seizures? *

Yes
No
Unsure

Is the individual hearing or vision impaired? *

Hearing
Vision
Both
No
Unsure

Is the individual able to co-exist in a communal environment with up to five roommates? *

Yes
No
Unsure

If incontinent, is the individual able to manage changing and cleaning themselves? *

Yes
No
Not incontinent

Is the individual diabetic? *

Yes
No
Unsure

Is the individual prone to falls? *

Yes
No
Unsure

Additional Notes on Care Requirements:

6) Activities of Daily Living (ADLs)

Please indicate the individual’s level of independence for each ADL (I = Independent, S = Needs Supervision, A = Needs Assistance, D = Dependent). Recuperative Care staff will follow up to discuss the details of the individual’s ADL assistance needs.

Bathing: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Dressing: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Toileting: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Transferring: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Eating: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Taking Medications: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

If you answered "Needs Assistance (A)" or "Dependent (D)" to any of the above, please explain.

Is the individual able to ambulate up to 50 feet to the bathroom independently? (With or without an assistive device) *

Yes
No

Is the individual able to ambulate up to 150 feet to the dining room independently using the elevator? (With or without an assistive device) *

Yes
No

Please indicate which device(s) the individual requires to be mobile:

e.g., wheelchair, walker, cane, portable oxygen, none

7) Social Factors

Social factors do not necessarily determine the individual’s appropriateness for Recuperative Care services, but rather assist RC staff in understanding the individual’s needs and goals.

Housing Status *

Chronically Homeless
Newly Homeless
Unstable Housing
Home is Unsafe
Unsure

Insurance Type: *

Partnership
MediCal
Medicare
Kaiser
Private Insurance
None
Unsure

Insurance Member ID:

Substance Use: Does the individual use alcohol or drugs recreationally? *

Yes
No
Unsure

Substance Use: is the individual interested in recovery/abstaining from substance use? *

Yes
No
N/A

Please describe the individual's behavior/mental health: *

e.g., Does the individual manage their mental health by taking medications as prescribed?

8) Primary Care Provider Information

Name:

First

Last

Practice/Clinic Name:

Phone Number:

Date & Time of Next Appointment:

9) Anything else COTS Recuperative Care staff needs to know when considering this referral?

10) Referring Person's Information:

Name: *

First

Last

Organization/Hospital: *

Relationship to the referred individual: *

Phone Number: *

Email: *

Your preferred contact method: *

Phone
Email
No Preference

11) Consent: Did you obtain the individual's consent to make this referral to COTS Recuperative Care on their behalf? *

Yes
No

12) I verify that the above information is true and correct based on my knowledge about the referred individual: *

True
False

Committee on the Shelterless
EIN: 68-0176855

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Locations

Mary Isaak Center (Emergency shelter and central offices)
900 Hopper, Petaluma

Kids First Family Shelter
1500 Petaluma Blvd S, Petaluma

Santa Rosa Office (client services for Santa Rosa City residents)
1421 Guerneville Road, Suite 200, Santa Rosa, CA 95403

Contact

[email protected]
(707) 765-6530

Mailing Address

PO Box 2744
Petaluma, CA 94953

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