Patient Referral

PATIENT REFERRAL TO ARK HOUSE

Instructions:
The following is a patient referral form for Ark House. If the information for a required field is not available (NA) you may enter "NA" or a field compliant response (e.g. NA@NA.com for the email). You will not be allowed to submit a referral with a required field blank.

The calendar function for selecting dates does not work properly with Internet Explorer. You will have to type in the dates in Internet Explorer. It has been tested and works with Edge, Chrome, and FireFox.

Required fields marked with an "*"

Referral Date*: (mm/dd/yyyy)

======= PATIENT INFO =======

First Name*:

Middle Name*:

Last Name*:

Patient's Permanent Address* (Must be greater than 50 miles from Dallas):
Street* :
City* :
STATE*:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingNot U.S.
ZIP* :
Country*:

Enter Patient Date of Birth:
Birth Month:* (Month: 1 to 12)
Birth Day.....:* (Day: 1 to 31)
Birth Year....:* (Year: 1910 to 2040)

Medical Condition/Diagnosis*:

Date Apartment Needed*: (mm/dd/yyyy)

How long is apartment needed (IN WEEKS)*: Weeks

U.S. Citizen with a SSN*:YesNo

======= PRIMARY POINT OF CONTACT FOR PATIENT/FAMILY =======
The person identified should be the primary point of contact for Ark House completing the application process and during the time the patient and/or family is residing in Ark House. The PPOC may be the patient, a family member, or a caregiver staying with the patient.

First Name*:

Last Name*:

Relationship to Patient:SelfSpouseParentSon/DaughterSiblingGrandparentUncle/AuntCareGiverFriendOther

Phone (Cell Preferred)*:

Email*:

======= REFERRER INFO =======
First Name*:
Last Name*:
Role*:
Phone (Cell or Call Back)*:
Referrer Email*:
Medical Facility Providing Treatment*:
Notes:
ALL adult occupants (18 years or older), including patient and all caregivers, must have an SSN and pass a criminal background check. Foreign Nationals MUST be in the U.S. legally with documents to reside in Ark House.
Ark House is set up for two residents at a time, with provisions for occasional visitors. A sleeper sofa provides for two additional residents and occasional guests.
After reviewing your inputs and assuring all required fields have an input, you may check the box below and then submit the referral. You will receive an email verifying its submittal to Ark House.
Please review your inputs, check the box, and then press the "SUBMIT REFERRAL" button.
After submitting, scroll down to see the submittal confirmation message.