Medical Respite Program Information Items indicated with a (*) are required. Medical Respite/Recuperative Care Directory Program Submission Form Name of Medical Respite/Recuperative Care Program* Year of Program Establishment Name of Operating Agency* Address* Street Address Address Line 2 City State ZIP / Postal Code Program Contact* Include full name and title.HiddenPhone NumberEmail* Website HiddenProgram Description*Provide a concise, narrative description of your program. Program descriptions are generally one or two paragraphs long and should not exceed 250 words. Consider copying existing narrative from your program website, grant applications, etc.Mission & Vision*Operation Agency Type*Non-ProfitHCHHospitalPublic AgencyOtherFacility Type*Apartments/Motel RoomsALF/Nursing HomeHomeless ShelterStand-Alone FacilitySubstance Use TreatmentOtherTotal Number of Respite Beds* HiddenHours of OperationAverage Length of Stay HiddenAdmission CriteriaClinical Staff Physician Physician Assistant Nurse Practitioner Nurse Social Worker Community Health Worker Other Select all that apply.Clinical Services Provided(Examples: Wound care, medication-assisted treatment, IV antibiotics, behavioral health care, etc.)Support Services Provided During Medical Respite/Recuperative Care Stay Meals Transportation Case Management (including housing assistance, benefits acquisition, etc.) Other Check all that apply.Funding Source(s) for Medical Respite/Recuperative Care Program Hospital HRSA HUD Medicaid/Medicare Private Donations Local/State Government Local Government Religious Organization Foundations United Way Other Check all that apply.Is Your Program a Member of the National Health Care for the Homeless Council?*YesNoUnsure
