A.1 Renown Respite Home Referral

Renown Respite Home
Life Changes, Inc. P.O. Box 3137, Sparks, NV 89432 775.685.8145, LifeChangesinc@yahoo.com
EXCLUSION CRITERIA
- Member's medical condition requires a higher level of care than what home health care can/should provide
- Member is not medically or psychiatrically stable and requires greater care than can be accommodated by "Respite"
- Member is unwilling to engage in abstinence during attachment to "Respite"
- Member is a sex offender (no exceptions)
- Member has outstanding warrants (no exceptions)
- Member has engaged in crimes against elders or minors (no exceptions)
- Member has been convicted of arson.
Name
DOB
Medicaid/Medicare #*
Health Insurance Provider*
REFERRING PARTY
Name*
Phone #
Email
example@example.com
Anticipated (approximate) date/time of discharge from hospital care:
Anticipated (approximate) arrival time & method to respite care:
Does Applicant have discharge prescriptions?

YesNo
If yes, are prescriptions handwritten or electronic?

HandwrittenElectronic
Does applicant currently have any of the following symptoms? Choose all that apply

Fever or ChillsCoughShortness of Breath or Difficulty BreathingFatigueMuscle or Body AchesType option 5Nausea or VomitingHeadacheNew loss of taste or smellSore ThroatCongestion or Runny NoseSwollen Lymph NodesDiarrheaNone of the Above
During the past 14 days, has applicant been in close physical contact (6 feet or less) with any of the following? Choose all that apply:

Someone with known COVID-19Someone with known Monkey PoxSomeone with COVID-19 symptomsSomeone with Monkey Pox symptomsNone
Reason for respite bed: (describe medical conditions)
Medical Diagnosis
Behavioral Health Concerns (Mental Health/SUD)

Behavioral HealthSUD
Legal
EVER been convicted of a crime that is sexual in nature?

YesNo
EVER been convicted of arson?

YesNo
EVER been convicted of a crime against a minor or senior?

YesNo
Ambulatory Supports
Ambulatory supports must be provided to resident member prior to arrival at non medical respite home. Please list equipment provided in detail.
Does resident member have the ability to ambulate and attend to his/her ADLs without assistance? NOTE: If it is determined a client is unable to ambulate and attend to his/her own ADL’s and require a higher level of care, they will be returned to the hospital/referring entity of origin.

YesNo
Should be Empty:

Renown Respite Home

REFERRING PARTY

Legal

Ambulatory Supports