redrockhaven.org

  • Phone: 404.500.7644
  • Phone: 404.500.7644
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Red Rock Haven

Hospital / Agency Referral Form

Form Date

Date *

Referring Hospital / Agency Information

Client Information

Date of Birth *

Gender

Insurance Status

Income Source

$

Current Living Situation

Does the client need stable housing after discharge?

Functional Eligibility Screening

Is the client able to live independently without hands-on personal care assistance?

Mobility Status

Please confirm the resident:

Resource Navigation / Case Management Assistance

Does the client need supportive coordination services?

Medical / Behavioral Summary

Is the client currently stable for community housing placement?

Discharge & Placement Details

Anticipated Discharge Date

Potential Move-In Date

Emergency Contact / Family Contact

Legal Guardian / POA (If Applicable)

Required Documents

Upload Documents

Attach referral documents, discharge summaries, medication lists, or other supporting files.

Program Acknowledgement

Red Rock Haven is a structured housing program for independent and semi-independent adults.

Red Rock Haven does not provide assisted living services, skilled nursing care, or hands-on personal care services.

Supportive services may include resource navigation assistance and coordination with outside providers and community agencies.

Fields marked with * are required. Please review all sections before submitting.