Life Tree Foundation – Life Tree Foundation

A hospital case manager, discharge planner or social worker can submit a patient referral 24 hours a day, 7 days a week. We accept clients 8:30 AM-5:00PM, seven days a week. Complete referral form and fax to (909) 254-6800 along with Hospital Face Sheet, History & Physical, and any additional documents. Contact Bridge Health & Life Tree Foundation at (888) 354-6993 with any patient referral questions.

Hospital Name:

Hospital Admit Date:

DD slash MM slash YYYY

Attending Physican:

First Last

Anticipated Hospital DC Date:

DD slash MM slash YYYY

Patient

First Last

MRN #

DOB

DD slash MM slash YYYY

Gender ID

Male

Female

Trans Man

Trans Woman

Hospital Admission Diagnosis:

Hospital Admission

Hospital Emergency Room

Allergies:

Insurance Type:

Request

Home Health Wound Care

Home Health IV

Home Health Physical Therapy

Home Health

Recup Licensed Board & Care

O2 Concentrator

Netw. SNF

Recup Independent Room & Board

Independent ADL's

Yes

No

Walks greater than 100 ft

Yes

No

Can patient transfer to toilet?

Yes

No

Does patient have assistive device need?

Yes

No

Please check:

Walker

Cane

Crutches

Wheelchair

Is patinet continent of bowel and bladder?

Yes

No

If in continent, can change own diaper?

Yes

No

Colostomy care?

Yes

No

Any isolation?

Yes

No

What kind of isolation?

Self-administer medications?

Yes

No

Diabetic?

Yes

No

Requires insulin?

Yes

No

Requires Glucose Testing?

Yes

No

Patient have any critical outpatient services?

Yes

No

Please check:

Hemodialysis Dyalsisy

Out-patient

Radiation/Chemo Therapy

Tuberculosis

Yes

No

Oxygen?

Yes

No

Bipap?

Yes

No

Cpap?

Yes

No

Subacute

Teach

Vent

Suction

Feeding

Self

Bowlus

GTube

Alert Status

X1

X2

X3

X4

Diet Type

Any Wounds?

Yes

No

Patient competent in wound care?

Yes

No

Wound Change Freq:

Stage of wound?

Wound Vac?

Yes

No

Does the patient have any drains?

Yes

No

What kind of Drain?

Any surgical procedures during this hospitalization?

Yes

No

If surgical, does the patient have a F'up appt?

Yes

No

Did the patient have a psychiatric consultation in the hospital?

Yes

No

On psychiatric meds?

Yes

No

Psychiatric diagnosis?

Bipolar

Depression

Schizophrenia

Past History of Suicidal Ideation

Does patient have any substance abuse issues?

Alcohol

Cocaine

Heroin

Methamphetamine

Other Type

Did the patient have a psychiatric consultation in the hospital?

Yes

No

Hospital Staff

Hospital Staff Title

Electronic Signature

Date

DD slash MM slash YYYY

Consent

Hereby assert that the information provided is correct.

Submission Hospital