Placement Referral — Caring Hearts

Please complete this referral to support a safe and accurate placement decision. We use this form to perform an initial fit & safety review. If the resident is a potential match, we will complete an in-person assessment to confirm information, physical needs, and transportation plan.

Download PDF Referral Form Call (713) 824-0017 Email info@healinghadc.org

Referral Intake Form

Complete Step 1 to unlock Step 2. We use this information to prepare for your in-person assessment and verification.

Step 1 — Referring Party

Referring Organization / Facility

Contact Name

Direct Phone

I confirm I’m authorized to share this information for placement review.

I’m not a robot

Step 2 — Resident Details

Resident Full Name

DOB

Requested Move-in Date

Current Location

Reason for Placement / Key Notes

Step 3 — Fit & Safety

Primary Diagnosis

Mobility

Awake overnight often?

Requires 1:1 / sitter?

Behavior / Wandering / Aggression notes

Step 4 — Medical, Payor & Documents Medical / Skilled Needs (oxygen, wounds, diabetes, devices, recent hospitalization)

Primary Payor

Managed Care Plan (if any)

Documents Upload (if available)

I understand we will confirm all information during the in-person assessment (including physical assessment and transportation plan).

Thank you — your referral intake has been submitted.