Forms from HCH Projects

The tools listed below are samples of forms in use by Health Care for the Homeless projects. Our intent is to offer practical examples of various approaches to common problems, providing a framework for your organization to adapt, revise and build upon. While these tools reflect current standards, inclusion of materials in our collection in no way implies recommendation or endorsement of a particular item. Many of the documents are in PDF format.

Waterfront Rescue Mission, Fort Walton Beach, FL

These health care protocols were developed to help non-medically trained shelter workers make appropriate referrals by addressing when and where to refer homeless individuals for health care services.
Adult Chronic Medical Concerns Protocol | May 2010
Adult Chronic Mental Health Protocol | May 2010
Adult Cold & Flu Protocol | May 2010
Adult Dental Needs Protocol | May 2010
Adult Life-Threatening Medical Protocol | May 2010
Adult Urgent Mental Health Protocol | May 2010

Health Care for the Homeless Network, Seattle, WA

Pediatric Protocols

HCH, Inc., Baltimore, MD

Baseline Information
Consent For Release Of Medical Information
Request For Medical Records From Another Facility
HCH, Inc./CONNECT Initial Updated Assessment Form
HCH, Inc./CONNECT Nursing Assessment Form
Interdisciplinary Assessment Form
Multidisciplinary Problem List
Progress Notes
Addiction Assessment Tool
Addiction TB Screening Assessment Form
Addiction Discharge Summary
Treatment Plan: Diagnosis and Formulation of Problems
Addiction Aftercare Plan
Addiction Recovery Verification of Attendance Form
Addictions Treatment Behavioral Contract
Addiction Checklist
Confidentiality of Alcohol and Drug Abuse Clients
Medical Team Encounter Record
Community Health Outreach Encounter Record
One Touch Blood Glucose Monitoring System: Daily Quality Control Record
Convalescent Care Admission/Referral
HCH, Inc. Diagnostic Testing Follow-Up Form
Group Immunization Influenza Vaccine
Health History Dental for Referrals
Health Maintenance Sheet
History and Physical Form
Informed Consent and Agreement to HIV Testing
Laboratory Processing Log
Medication Admin Record One-Time Orders
Referral Form
Statement of Client Declination of Advice or Plan of Care Offered at HCH, Inc.
Medication Inventory Tracking Sheetet
Walk-In Client List
For urgent needs after 5 pm and weekends / Date & Time Provider Sheet
Mammogram Questionnaire
Mental Health Team Encounter Record
UM Medical Center/HCH, Inc. Psychiatric Evaluation Psychiatric Evaluation
Psychiatry Follow-up Visit
Psychological Assessment
Case Management Progress Note
Interdisciplinary Care Plan
Psychosocial Case Management Assessment

Camillus Health Concern, Miami, FL

Document Folder – Financial Assessment; Progress note; Pediatric Progress Note; Comprehensive Pediatric History; Adolescent Health Maintenance Assessment; HIV Specific Flow Sheet

Camillus Folder – Psychosocial Report; Financial assessment/Sliding Fee Scale; Registration Form; Patient Grievances; Women’s Health Visit; Health Maintenance Assessment – 1 month; Health Maintenance Assessment – 2 month; Health Maintenance Assessment – 4 month; Health Maintenance Assessment – 6 month; Health Maintenance Assessment – 9 month; Health Maintenance Assessment – 12 month; Health Maintenance Assessment – 30 month; Health Maintenance Assessment – 3 year; Health Maintenance Assessment – 4 year; Health Maintenance Assessment – 5 year; Health Maintenance Assessment – 6 year; Health Maintenance Assessment – 7-12 year; Adolescent Visit; Comprehensive Pediatric History; Dental Record; Pediatric Progress Note – Episodic; Adult Progress Note – Episodic; Preventive Care Data Form, Diabetes Maintenance Form, Consumer Responsibilities, Consumer Rights

Homeless Health Care, Los Angeles, CA

Admission Agreement
ASI Employment
ASI Legal Status
ASI Med-Drug
ASI Psychiatric Status
Child Participation
Client Registration
Confidentiality of Client Records
Discharge Summary
Initial Screening Form
Intake Form
Release of Information Consent
Sexual Conduct Policy
Treatment Plan 90 Day
Treatment Plan Update

Northeast Valley Health Corporation, San Fernando, CA

TB Screening/Referrals
Domestic Violence Workshop