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This section includes a carefully selected sampling of respite-specific policies and procedures, and programmatic forms which you are welcome to use and adapt to your own needs. These are organized into the following broad categories: policies and procedures; referral/screening forms; intake/admission; forms used during stay; and miscellaneous. All of the documents are either in Adobe or Microsoft Word formats. If you have any questions or suggestions about these tools, or if you are willing to share some from your own respite program, please contact Sabrina Edgington at sedgington@nhchc.org.
POLICIES AND PROCEDURES
Policies and Procedures Manual
McInnis House (Boston, MA)
Program Guidelines
JWCH Institute, Inc. Recuperative Care Program (Los Angeles, CA)
REFERRAL/SCREENING FORMS
Screening Forms
Homeless Health Care (Los Angeles, CA)
Referral Forms
COTS Mary Isaak Center (Petaluma, CA)
Seattle, WA
McInnis House (Boston, MA)
Harmony Health Recovery Center
(Houston, TX)
INTAKE/ADMISSION
Client Agreement/Contract
Homeless Health Care (Los Angeles, CA)
Admission/Intake Forms
Respite Client Info 3-1-06 (Seattle, WA)
Respite Client Admit-Discharge 3-1-06 (Seattle, WA)
Database Intake and Discharge Form (Samaritan House, Denver, CO)
Homeless Health Care (Los Angeles, CA)
Admission Check List (McInnis House, Boston, MA)
Intake and Assessment (McInnis House, Boston, MA)
Routine Admission Orders (McInnis House, Boston, MA)
Health Diagnosis/Assessments (Medical, Psychosocial, etc.)
Employment and Support Assessment (Homeless Health Care, Los Angeles, CA)
Family/Social Relationships Assessment (Homeless Health Care, Los Angeles, CA)
Psychiatric Status Assessment(Homeless Health Care, Los Angeles, CA)
Addiction Severity Index (Homeless Health Care, Los Angeles, CA)
Legal Status Assessment (Homeless Health Care, Los Angeles, CA)
Psychiatric Evaluation (Harmony Health Recovery Center, Houston, TX)
Medical Diagnosis (Harmony Health Recovery Center, Houston, TX)
FORMS USED DURING STAY
Treatment Plan
McInnis House (Boston, MA)
Vital Signs Sheet
McInnis House (Boston, MA)
Status report/Progress Notes
Respite Nursing Encounter Log P1 3-1-06 (Seattle, WA)
Respite Nursing Encounter Log P2 3-1-06 (Seattle, WA)
Respite MH Encounter Log P1 3-1-06 (Seattle, WA)
Respite MH Encounter Log P2 3-1-06 (Seattle, WA)
Colorado Coalition (Denver, CO)
McInnis House (Boston, MA)
Discharge Outcomes Form/Discharge Summary
San Francisco Medical Respite & Sobering Center (San Francisco, CA)
McInnis House (Boston, MA)
MISCELLANEOUS
Job Descriptions for Respite Staff
Colorado Coalition – Denver, CO
Nurse
Case Manager
DISCLAIMERS
Copyright Status: Unless stated otherwise, these documents and files are in the public domain, and can be freely downloaded and reproduced.
Endorsement: While these tools reflect current standards, inclusion of materials in this collection in no way implies recommendation or endorsement of a particular item.
Liability: Neither The National Health Care for the Homeless Council nor any of its employees assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately owned rights.
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Additional policies and clinical tools
including those more general to homeless health care provision, are in the Clinical Practice Resources section of our website. |
