Skip to content
Search for...
Who We Are
What Is Medical Respite Care?
What Is NIMRC?
Our Staff
Advisory Panel
Respite Care Providers’ Network
Leading Voices
Resources
Medical Respite/Recuperative Care Directory
Medical Respite/Recuperative Care Tool Kit
Training & Technical Assistance
Reports, White Papers, and Issue Briefs
Respite & Recuperative Care News
Recent Webinars
News
Contact Us
Toggle Navigation
Toggle Navigation
Who We Are
What Is Medical Respite Care?
What Is NIMRC?
Our Staff
Advisory Panel
Respite Care Providers’ Network
Leading Voices
Resources
Medical Respite/Recuperative Care Directory
Medical Respite/Recuperative Care Tool Kit
Training & Technical Assistance
Reports, White Papers, and Issue Briefs
Respite & Recuperative Care News
Recent Webinars
News
Contact Us
Medical Respite/Recuperative Care 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.
Phone Number
Email
*
Website
Program 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.
Operation Agency Type
*
Non-Profit
HCH
Hospital
Public Agency
Other
Facility Type
*
Apartments/Motel Rooms
ALF/Nursing Home
Homeless Shelter
Stand-Alone Facility
Substance Use Treatment
Other
Total Number of Respite Beds
*
Hours of Operation
Average Length of Stay
Admission Criteria
Clinical 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?
*
Yes
No
Unsure