Hotel shelter program referral, hotel transfer and respite form

* Indicates a required field

Referral Identification Number *

Referring shelter/agency: *

Referring shelter/agency phone number: *

Referring shelter/agency email address: *

Name of client: *

Date of birth:

Month

Day

Year

HMIS:

Next of kin/family contact and phone number:

Do they have a Ramsey County worker?

Yes

No

List all known workers:

Do they have any medical needs, underlying conditions or medications?

Yes

No

List all known medical needs, underlying conditions, medications:

ie. walker/wheelchair/etc.

Have they been in a hotel/shelter placement before?

Yes

No

Prior hotel placement and reason for discharge/ transfer:

Do they have any current COVID-19 symptoms?

Yes

No

Current COVID-19 symptoms:

Will they be staying in the same room with a spouse/partner?

Yes

No

Name of spouse or partner:

Have they been quarantined for COVID-19 or symptoms before?

Yes

No

Quarantine date completed:

Month

Day

Year

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