MEDICAL REFERRAL FORM

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Samaritan House Referral & Info

To be used by authorized medical facilities and personnel ONLY

Attention Medical Personnel:

If this is your first time making a referral to Samaritan House, please read our “Referral Process” below before downloading the “Screening Evaluation/Referral” and “Guest Rules”.

After completing the Screening Evaluation/Referral please fax back to Samaritan House along with the signed Guest Rules. We will contact you once we have reviewed the referral. Please be sure to leave an active contact number for us to contact you. THANK YOU.

Samaritan House Screening Evalation

Samaritan House Guest Rules

IMPORTANT! PLEASE READ BEFORE MAKING A REFERRAL

Samaritan House is NOT able to accept guests:

  • Using oxygen
  • Have a colostomy bag
  • Having an open IV
  • Currently taking Methadone
  • Who have incontinence issues

Please keep in mind that patients being referred to Samaritan House MUST either be admitted into the hospital or currently checked into the emergency department. We cannot accept referrals for those that have been discharged from the hospital and/or emergency departments.

As we do not maintain a “waiting list”, our bed space is on a first come, first serve basis, once the patient is discharged from the hospital and/or emergency department, they are no longer eligible for intake to Samaritan House.

In our attempt to avoid any miscommunication, and because Samaritan House is not a shelter, we ask that social workers, nurses, doctors and/or other medical personnel to please not inform any patient to call Samaritan House after discharge for possible placement.

Mental Health Diagnosis

Referring patients with mental health issues, please be advised of the following:

If patient has a diagnosed mental health issue, in order to be accepted at Samaritan House, it should be documented and verified by a mental health professional that the patient is stable. Also, if the patient has been prescribed psychotropic medications it should also be verified that the patient has been on those medications for at least 21 continuous days.

Please contact Samaritan House directly prior to submitting a referral for a patient that does have mental health issues.

For more information and instructions on making a referral, please read below. Thank you for your understanding and continued cooperation.

Samaritan House Intake – Referral Information

Admission is on referrals from hospitals and authorized medical providers ONLY(Primarily from hospital social workers)

Samaritan House will make every effort to pick patients up from the hospital. In the event we cannot, it is up to the referring facility to arrange for transport. Due to liability reasons, please keep in mind the following:

  • Patient CANNOT travel by CATS Buses.
  • Patient CANNOT be transported by friends and/or family
  • If patient is being transported by a taxi service, it is important that the service know that the patient must be transported straight from facility to Samaritan House, there is to be no stops made for any reason (unless previously authorized by Samaritan House)

Social workers MUST fax in a completed referral form BEFORE patient can be considered for placement.

Guests are served on a first come, first serve basis when eligibility requirements are met.

We are a non-medical program, guests must be self-medicating and ambulatory.

Samaritan House IS NOT able to accept patients requiring oxygen, colostomy or an IV.

Referrals are accepted, evaluated and decided on Monday thru Friday 9:00am-10:00pm (non-holidays).

Due to having female staff and volunteers as well as minors who visit with volunteer groups, all guests are thoroughly screened for criminal background checks. We do not refuse those with criminal histories but the following are NOT accepted under any circumstances:

  • Patients listed on any local, state or federal sex offender registry
  • Patients with serious violent charges (murder, attempted murder, kidnapping, arson, etc.)
  • Patients with “Assault on Female” charges
    (Other charges involving domestic abuse or violence charges are reviewed by Brad Goforth for possible intake)
  • Patients with any child abuse charges or violence towards minors/children

We provide meals and 24 hour accommodations. Guest must be self-medicated, able to get around on their own and take care of themselves (shower, eating, getting in and out of bed, etc.)

Samaritan House staff are not trained or authorized to perform any non-emergency medical procedure (changing dressings, administering medications or treatments, treating wounds, etc.)

Bedside urinals and commodes ARE NOT allowed, guest must be able to use the bathroom and shower units (exceptions are made for guests who need to take temporary “bird baths” due to dressings, open wounds and/or casts)

Certain mental illnesses are accepted but those guests with mental illness when accepted MUST adhere to the following:

  • Must have been on current psychotropic medications for a minimum 21 days. If patient has been prescribed psychotropic medications and simply refuses to take them for any reason, patient will not be accepted.
  • Patient MUST be stable and coherent

**Contact Samaritan House for any referrals for any patients with any mental illness BEFORE submitting any referral**

Samaritan House provides transportation to and from all medical appointments (within Mecklenburg County ONLY) as well as prescription drop-off and pick-up, Social Security Administration matters, Urban Miinstries, and Crisis Assistance matters.

At this time Samaritan House DOES NOT provide financial assistance for any prescriptions.

Samaritan House provides limited resources for guests interested in obtaining housing or employment upon discharge as well as applying for social services matters (food stamps, disability, SSI, etc.)

Guests share a bedroom with up to 2 other guests. Each room has a full bathroom, and twin sized beds. There are no “private” rooms for any reason or exceptions medical or otherwise.

As prescribed and/or provided, guests may receive visiting nurses or physical therapists

Samaritan House DOES NOT accept patients:

  • In need of drug/alcohol treatment and/or rehabilitation. We are not a substance abuse rehab or detox facility and will not approve any referral for patients needing these types of facility
  • Who have a residence and/or a job, our facility is for the homeless
  • Who have an active, communicable or contagious illness
  • Under the age of 18 years old
  • Who are couples (married or otherwise) or patients with “live-in” medical aides
  • With their children in their custody
  • At this time we do not accept patients from hospitals and/or medical facilities outside of Mecklenburg County

All patients MUST read and accept the rules as per the “Guest Rules” as provided and on file with hospital social workers and it MUST be signed before referral is made/accepted

It is not our intention to make referrals difficult or refuse any referrals, it is strictly our intention to use this process to keep Samaritan House and its guests, staff, visitors and volunteers safe and to provide a safe, stable and clean facility. We ARE NOT a shelter, we are strictly and highly enforced SHORT TERM recuperative care facility with the goal of providing a place for those in need to properly recuperate and not return to the streets, local shelters or the hospital.

We invite and encourage all social workers, nurses and doctors associated with local hospitals and medical facilities to come and visit Samaritan House and see firsthand how we operate and provide our services

If you should have any questions or comments concerning the above information or Samaritan House in general, please feel free to contact the Executive Director Brad Goforth or

Facility Manager Gregg Chapman at (704) 333-0110

THANK YOU, WE LOOK FORWARD TO CONTINUING OUR RELATIONSHIP WITH EACH SOCIAL WORKER, HOSPITAL AND OTHER MEDICAL FACILITIES