Amani Recovery Care

Referrer Information

Your Full Name *

Agency / Role

Email Address *

Phone Number

Patient Information

Full Name *

Date of Birth

Phone Number

Email (optional)

PMI# (if available)

Clinical Information

Primary Diagnosis / ICD-10

Primary Care Clinic / Provider

Current Medical Needs

Hospital Discharge Date

Discharging Facility

Referral Details

Reason for Referral

Medically stable but lacks housing

Recently discharged with care needs

Needs supervision or transitional support

No safe/stable environment

Other (describe below)

If 'Other', please describe

Funding / Insurance Notes

Attachments

Consent & Authorization

Information Authorization

I authorize Amani Recovery Care to securely receive and use my information for the purpose of intake, care coordination, and admission review. I understand information will be stored securely and not sent by regular email.

I may withdraw my consent in writing at any time, subject to legal and care obligations.

By providing this information, I confirm that I have the authority to share these details for the purpose of care coordination.

I have read and agree to the consent statement above

Full Name for Consent *