Cordell Christian Home - New Admissions

If you or a loved one would like to become part of the CCH family, simply fill out the following form and submit it. Please allow one week for a response from one of our CCH representatives. Thank you.

Admission Inquiry

Name of Possible Admit:
Gender:
Transfer From:
Reason for Transfer:
Marital Status:
Type of Admission:
Diagnosed with a Mental Disorder?
If "Yes," please state diagnosis:
Insurance:	Medicare Medicaid Private Insurance
Smoker?
Preferred Admission Date:
Name and Address of Physician:
Has Possible Admit had any hospital stays within the last 3 months?
If "Yes," please state the name and address of the hospital.:
Any prior stays in a nursing home?
If "Yes," please state the name and address of the nursing home.:

Personal Contact Information

Your Name:
Relationship to Possible Admit:
Address:
City:
State:
Zip:
Phone Number:
E-mail Address:

Still trying to make the "nursing home decision"?
Here are some helpful links:

www.longtermcareliving.com/pdf/making_transition.pdf
http://www.geocities.com/~elderly-place/nursinghome. html
http://www.agingcare.com/

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