• Person Making Referral:
    • Phone:
    • Facility:
    • Patient Name:
    • DOB:
    • SS#:
    • Managed Care Plan:
    • Managed Care CM or Hospital CM Contact:
    • Phone & Ext.
    • Reason For Referral:
    • Primary Diagnosis:
    • Special Treatments: i.e. wound care, PT, IV ABTs, resp. care, glucose monitoring, Non wt. bearing : Please describe:
    • Medical Records: Admit H&P and Recent:
      MAR & Medications on Discharge (reconciliation)Labs & X-Rays & Diagnostic StudiesMD Progress notesDischarge Orders
    • Other Records:
      TB Status Last PPD or CXRBehavioral Diagnosis InformationPsychotropic MedicationsSpecial Equipment (DME) (Oxygen) or OtherSpecial Dietary Records
    • ADLs & Special Needs
    • Independent with ADLs YesNo
    • Recent Falls YesNo
    • Continent YesNo
    • If incontinent can change own Diaper YesNo
    • Is Patient Ambulatory YesNo
    • If not ambulatory independent with mobility YesNo
    • Is Patient Competent YesNo
    • History of Dementia or Alzheimer’s YesNo
    • History of MRSA or other isolation YesNo
    • History of recent substance use YesNo
    • If so Describe:
    • Signs of Withdrawal YesNo
    • Is pt. on Methadone YesNo
    • If so enrolled in a Methadone ProgramYesNo
    • Program information & Phone #:
    • Psych Diagnosis:YesNo DX:
    • Is Pt. Receiving Psychiatric CareYesNo
    • If so Where:

    Public Health Disclosure TB:

    All homeless persons are at risk for TB. Any homeless person with a new cough or change in cough for three weeks or with pulmonary symptoms suggestive of pneumonia
    must have CXR.

    There is a rise in the incidence of communicable diseases. In order to effectively manage client illnesses, CMIS requires that you report communicable diseases. This
    includes but is not limited to TB, VRE, MRSA, C-DIFF.

    If a patient has been identified to have scabies it is required that they have undergone treatment and have been cleared prior to admitting to the CMIS Program


    1. Must have a primary medical problem
    2. Must be physically and psychiatrically stable to receive care in a medical respite setting
    3. Must be in need of short term recuperative care
    4. Must be able to perform self- ADLs
    5. If on Methadone must be in a Methadone Program
    6. Must be mentally competent


    1. Scabies
    2. Quadriplegics
    3. C. diff / MRSA / TB
    4. Dementia/Memory Loss
    5. Combative/Violent behavior
    6. Hallucination/Delusion
    7. Bipolar schizoaffective
    8. Blind
    9. Sex offender
    10. Arsonist
    11. Unable to self-represent
    12. Unable to perform ADL and transfer with assistance
    • Length of respite stay (projected):
    • Interpreter language needed:
    Other Communications from Assessing or Referring Representative:
    Email Address