Patient Referral Form – Waterfront Mission

Arukah Referral Form

Date(Required)

Client Name(Required)

First Last

DOB(Required)

Primary Diagnosis(Required)

Healthcare Organization(Required)

Referred By(Required)

Contact Number(Required)

Is the patient homeless?(Required)

Yes

Expected date of hospital discharge(Required)

Requested length of stay in Arukah Respite:(Required)

If referral is approved, healthcare organization must provide patient’s transport to Arukah Respite for direct intake upon hospital discharge.

CAPTCHA

Please email this completed form to Tricia Cook, Program Manager of Arukah Respite Center

Once referral form has been received, you will be contacted as soon as possible.

Please call (850) 759-2265 if you have any questions.

*We will not accept any patient who has been convicted of a sex offense.

*A background check will be conducted to verify if patient is a sex offender, and

we must also check our system to verify if patient is under any bans for violence at our Mission.

We are a non-clinical facility; therefore, clients must be able to self-care and complete all their ADL’s.

*We cannot accept any patient who is incontinent.




By submitting this form, you are consenting to receive marketing emails from: Waterfront Rescue Mission, P.O. Box 870, Pensacola, FL, 32591, US http://www.waterfrontmission.org. You can revoke your consent to receive emails at any time by using the Unsubscribe link, found at the bottom of every email.




By submitting this form, you are consenting to receive marketing emails from: Waterfront Rescue Mission, P.O. Box 870, Pensacola, FL, 32591, US http://www.waterfrontmission.org. You can revoke your consent to receive emails at any time by using the Unsubscribe link, found at the bottom of every email.