Solstice Care Solutions, LLC — Placement Referral Request Form

Solstice Care Solutions, LLC — Placement Referral Request Form

Share referral and client needs to support housing or return-home-with-support placement planning.
Referring Professional
Referring Professional Full Name

First NameMiddle NameLast Name
Title / Role
Hospital / Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Best Time to Reach You

Hour Minutes

AM/PM Option
Is There a Discharge Deadline?
Client Information
Client Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Living Situation
Family or Support Person Involved in Discharge
Referral Reason & Goals
Primary Reason for Referral
Brief Description of Referral Circumstances
Requested Housing or Support Type
Desired Location or County
Desired Move or Discharge Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is Placement Needed Urgently?
Client / Family Preferences or Goals
Functional & Support Needs
Ambulation / mobility status
Activities of daily living assistance needed

Other
Medication management / support needed
Cognitive status / memory concerns
Behavioral or psychiatric support needs

Other
Supervision needs
Communication, hearing, and vision considerations

Other
Dietary needs
Fall risk
Other relevant care or support needs
Equipment & Clinical Support Information
Current DME / equipment in use

Other
Oxygen / respiratory support details
Wound / skin care needs
Skilled nursing / home health currently ordered or anticipated
Therapy needs

Other
Other services currently ordered or recommended
Discharge medication list available instead of full medication list
Funding / Financial
Primary funding / payment source
Approximate monthly income or budget
Medicaid status
VA benefits status
Financial decision-maker / POA name

First NameMiddle NameLast Name
Financial constraints or payment notes
Documents & Discharge Information
Are discharge summary or clinical records available?
Can you provide relevant records securely upon request?
Expected discharge destination if placement is not secured
Additional discharge instructions or restrictions
Upload relevant documents

Cancelof
Client Preferences
Preferred Setting
Room Preference
Smoking Preference

Other
Pet Preferences

Other
Transportation Needs

Other
Cultural or Language Considerations
Other Preferences or Special Requests
Authorization / Acknowledgment
Confirmation of information use for housing/support coordination
Acknowledgment of placement/resource coordination terms
Client consent/authorization status
Name of person providing referral

First NameMiddle NameLast Name
Date submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Solstice Internal Use
Referral Received Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assigned Solstice Staff

First NameMiddle NameLast Name
Placement Status
Follow-up Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provider / Community Contacted

Other
Outcome / Notes
Should be Empty:

Solstice Care Solutions, LLC — Placement Referral Request Form

Referring Professional

Client Information

Referral Reason & Goals

Functional & Support Needs

Equipment & Clinical Support Information

Funding / Financial

Documents & Discharge Information

Client Preferences

Authorization / Acknowledgment

Solstice Internal Use