FISHER HOUSE REFERRAL FORM

 

 

 

Patient Name:___________________________† Ward/Room:__________†† Ward/Room Phone #:___________

††††††††††††††††††††† (Last Name,† First Name)

 

Grade or Sponsorís Grade:_________††† SSN:___________________††† Estimated Length of Stay:___________

 

Check all that apply:† I = VSI/SI ____††† II = Life Threatening Surgery/Illness____††

III = Patient Undergoing Treatment/Evaluation____† IV = No Friends/Family in Local Area____

 

Distance traveled (> 40 Miles) Yes (__)† No (__)†††† Family has friends/family in local area: Yes (__)† No (__)

 

Can family pay commercial lodging rates: Yes (__) No (__)†† Can family pay FH service fee:† Yes (__) No (__)

 

OIF/OEF: Yes (__) No (__)†† Air Evac: Yes (__) No (__)†† Funded Orders: Yes (__) No (__)

 

Family has transportation:† Yes (__) No (__)†††

 

Hardship or other assistance needed:† Yes (__) No (__) if yes, also refer to Chaplains, AER, Red Cross, ACS

 

Any exposure to a recent contagious illness (Chicken Pox, Flu, Measles, Hepatitis, etc.)† Yes (__) No (__)

 

Fill out the number of guest(s) and Names of Patientís caregiver seeking lodging at the Fisher House:

 

(Name)†††††††††††††††††††††††††††††††††††††††††††††††††† (Relationship to patient)††††††††††††††††††† (Age if under 21)†††††

1.

 

 

2.

 

 

3.

 

 

4.

 

 

 

Location where guest are staying:_____________________

Phone number where guest can be contacted:____________

 

Do guest(s) have any special needs: ____________________________________________________________

_________________________________________________________________________________________

 

STAFF NOTES

____________________________________________________________________________________________________________________________________________________________________________________

 

 

Healthcare Providerís Name (Print & Sign): ____________________________________†††††† Date:__________

 

Instructions:† Patientís families for whom Fisher House services are appropriate, may be identified by a healthcare provider, chaplains or the American Cross at the medical facility.†