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Receiving Zone Contact
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Referring Case Manager Contact
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Client Information
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Current Location
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Current Location
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Client Assessment (Complete as applicable)
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Assessed Level of Care (optimal)
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Waitlisted in Current Location
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Preferred Community or Location
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Client prefers alternate temporary site in current city/zone
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Client prefers alternate temporary site in receiving zone (close to preferred site)
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Person to Contact for Clinical Information and/or Updates
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Complete this section if the contact is different from referring case manager listed above
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Name
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Role
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Email:
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Comments:
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Documents/Information Attached or Included
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Resident assessment instrument - Home Care (RAI-HC)
ensure updated with any significant change in status since last assessment if greater than 6 months old
Note: assessment tools may vary across jurisdictions. Appropriate interRAI instruments may be considered
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(alternate decision maker, family/support person)
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(Please include treaty number, if applicable. If client is from out of province, please include date applied for AB health care)
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(for clients who have a history of an acute or chronic infection)
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(completed within 1 year, dated and signed)
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(e.g. GCD/GCD Order, financial decision-making documents, enactment documents, etc.)
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(e.g. best possible medication history and/or medication review (within 30 days) and MAP level)
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(e.g. comprehensive care plan, behavior support plan, bedside care plan, and/or wound care plan)
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(e.g. oxygen, wound, ostomy & continence supplies and/or equipment) Note: Please ensure detailed supply & equipment needs listed
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(e.g. cultural preferences, reunification requests, language needs, tobacco/substance/alcohol use, bariatric, dialysis, dietary/
nutrition, respiratory, etc.)
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(e.g. cultural preferences, reunification requests, language needs, tobacco/substance/alcohol use, bariatric, dialysis, dietary/
nutrition, respiratory, etc.)
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