IHS Hospital REFERRAL FORM
HRef.001-LD
Kaaahi Women/Family Shelter
546 Kaaahi Street
Honolulu, HI 96817
Ph (808)-845-7052
Fax (808) 845-7357
Sumner Men’s Shelter
350 Sumner Street
Honolulu HI 96817
Ph (808) 537-2724
Fax (808) 537-2697
The purpose of the IHS Hospital Referral Form is to ensure that individuals being referred to IHS are appropriately accommodated
and will receive proper attention and follow-up upon arrival. Organizations should not attempt to send individuals to IHS until the
referral form has been approved.
Reason for Hospital/Care Admission: ___________________________________________________________________________
Diagnosis (es): ______________________________________________________________________________________________
Physician: _______________________________________ Physician Contact Number: __________________________________
Medications: _______________________________________________________________________________________________
Mental Health/ Chemical Dependency Status:
1. Current Mental Status: Alert Oriented to time/place Memory loss: Short-term Long-term Both
2. Mental Health History: _____________________________________________________________________________
3. History of violent behavior?
YES NO ______________ 9. History of suicidal behavior? YES NO ___________
4. Compliant with medication?
YES NO N/A
5. History of substance abuse/chemical dependency?
YES NO If yes, list substance(s): ________________
6. Drug Screen Results? Pos. for ______________ Neg
7. Length of current hospital stay? ____________________
8. Length of time in state of Hawaii? ___________________
10. Reason/ dates of last admit(s)? _________________
______________________________________________
11. AMHD eligible?
YES NO
CM Name: __________________
Contact #: __________________
12. Income (source & amount): ____________________
Ability to Perform Activities of Daily Living (ADL’s) without assistance:
Walk at least 30 feet? YES NO
Ambulatory aides (wheelchair/walker)?
YES NO
If yes, able to transfer independently?
YES NO
Get in/out of bathroom stall w/o assist? YES NO
Feeds self? YES NO
Toilet self? YES NO
Bathe self? YES NO
Maintain good hygiene? YES NO
Ability to communicate w/ English? YES NO If no, what language? ______________________________________
Medical Condition:
1. Positive PPD? YES NO Date done: _______ Date Read: _______ Chest X-ray date: _______ Results: Pos. / Neg.
2. Stable. Does not require follow-up? YES NO
3. Can self-administer & monitor own meds? YES NO
4. Adherent to all aspects of medical care? YES NO
If no, please explain: ____________________________
5. Intact immune system?
YES NO
6. History of known communicable disease?
YES NO
If yes, list: _________________________________
7. Other external appliances?
YES NO
If yes, able to manage independently?
YES NO
8. Special diet requirements? _____________________
Other Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Referral Organization: _________________________________
Address: ___________________________________________
Contact Person: ____________________________________
Phone: ___________________ Fax: ____________________
Individual Being Referred: _______________________________
SSN: ________________________ DOB: ____________________
Height/Weight: ____ft. ____ in. ____ lbs.
Male Female Transgender
FOR IHS USE ONLY
Status of Referral:
Approved with stipulations _______________________________________________________________________
Need for Information, please call ___________________ at ____________________
Denied Reason(s): Shelter at full capacity Individual is suspended from IHS
Other: ______________________________________________________________________
IHS Signature: _____________________________________ Date: __________________ Time: ______________
IHS Staff (printed name): _________________________________ Position: _______________________________
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