Resident Referral Form

Aluna Bridge Guesthouse Referral Form

Thank You for the Referral!
Aluna Bridge is a 501(c)(3) nonprofit whose mission is to offer non-medical, compassionate, hospice care and support to women and children who are also experiencing housing insecurities. We hold sacred space for our underserved community members to spend their remaining days in a REAL home, surrounded by care companions who offer unconditional love, comfort, and dignity. We help our residents find honor and purpose in the life they have lived and help guide them towards inner peace and calm as they transition out of this world and into the next.

Knowing that many of our residents come to us after living out on the streets or in the wilds of tent camps and forests, our Guesthouse and entire nonprofit model is inspired by the cycles and seasons of nature, calling in the gentle rhythmic reminders of just how interconnected we as humans are with our nature allies and the greater mysteries of the earthly plane that has been hosting wee humans for thousands of years. It is through the buzz of bee hives, the honks of geese flocks and gentle gathering of bunnies and butterflies that we see the importance of community and the guidance of the Divine, leading us through our beautiful messy lives.

We welcome referring providers who share our mission and want to help us hold this sweet, sacred container. We believe that tending the Holy threshold of dying and bereavement is not only a gift to our Residents, but is also a gift to all who witness the greater mystery of death and the many ways it can become a portal to deeper reflection for ALL as to what it means to really live as stewards on this planet.
Step 1: Please review our FAQ page on our website in hopes of answering any questions you may have prior to referring a resident. Keep in mind, we ONLY offer housing and NON-MEDICAL support.
Step 2: Does your patient meet the minimum eligibility requirements?
Minimum Requirements:
- Eligible for hospice and being followed by a hospice provider/medical care team
- Signed DNR
- Prognosis of 6 months or less
- Currently does not have access to housing or is at risk of losing housing
- Has housing but no friends or family for companionship
- Is your patient a female and/or child without access to housing.
- Is not currently exhibiting nor has a history of exhibiting violent, combative behaviors.
- Is not currently diagnosed with an infectious disease, illness, or condition that would put our other residents & caregivers at risk.
- Non-smoking (we are a 100% nonsmoking property). Please ensure your patient is aware prior to referring
PLEASE NOTE: Our Guesthouse provides semi-private/shared spaces in a non-medical/non-clinical setting. We are in a regular single-family, residential home; therefore, we have to take additional steps to safeguard our residents, caregivers, and volunteers from potential high risks.
Step 3: If minimum requirements are met, please complete and submit the referral form below attaching any required records to help us triage our referrals based on a careful needs analysis.
PLEASE NOTE: All information shared is confidential and HIPAA compliant. We will contact you with additional questions or to coordinate transfer of patient into our home. We are only able to accommodate 4 residents at a time, so please be advised we may need to initially add your referral to our waitlist.
Name of Hospice Agency following patient's care
Date of Referral

MonthDayYear
Date
Time of Referral

Hour Minutes

AM/PM Option
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address (If the patient is housed but struggling to pay rent, utilities, etc.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale
Age
Current county of residence:
Medicare
Medicaid/Other
Allergies
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Physician Name

First NameLast Name
Phone Number
Please enter a valid phone number.
I certify that this patient is under my care and that I, or a nurse practitioner, clinical nurse specialist or physician's assistant working with me, had a face-to-face encounter with this patient on Date .
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for a prognosis of 6 months or less and requiring the patient receive hospice home health care.
Does the patient have the capacity to make sound decisions?
If they do not have the capacity to make sound decisions, do they have someone who has been appointed to sign for them or has agreed to sign for them?
Primary Diagnosis
Date of Hospice Diagnosis

MonthDayYear
Date
Is the patient and/or patient representative understanding of and agreeable to hospice care?
Present location of patient
Reason for current hospitalization
How many times has the patient been hospitalized in the last year?
Are there any issues of concern with family members/partners (ex: domestic abuse, neglect, etc.)
If yes, please explain:
Is the patient taking any medications other than for comfort/palliative care needs?
If yes, please list (please include name, dose, and route) and advise of who on the hospice team will be managing the patient's medications?
Does the patient have wound care needs?
If yes, please explain.
Approximate Weight:
Approximate Height:
Cognitive Status
Nutritional Status
Bowel/Bladder Needs
Ambulatory Status
Please review and choose all that apply:

Is currently chemically restrainedHas been chemically restrained at some point since being hospitalizedIs currently physically restrainedHas been physically restrained at some point since being hospitalizedHas not required any kind of restraint since being hospitalized
Please provide any additional information you feel we would need to know to help us triage the patient's needs to determine how we can best accommodate in our semi-private shared setting.
Please upload copy of signed DNR. Reminder this is a minimum requirement for our residents.

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Is the patient a minor (under the age of 18)?
Primary Caregiver Information - If applicable

(If a minor, must have an assigned caregiver)
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient
Referring Provider Information
Referring Physician Name

First NameLast Name
NPI
License Number
Date

MonthDayYear
Date
Signature

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Aluna Bridge Guesthouse Referral Form

Step 1: Please review our FAQ page on our website in hopes of answering any questions you may have prior to referring a resident. Keep in mind, we ONLY offer housing and NON-MEDICAL support.

Step 2: Does your patient meet the minimum eligibility requirements?

Step 3: If minimum requirements are met, please complete and submit the referral form below attaching any required records to help us triage our referrals based on a careful needs analysis.

Primary Caregiver Information - If applicable

Referring Provider Information