Dempsey Center›Clayton’s House Provider Information + Referral Hub›Clayton’s House Care Partner Exemption Form

Clayton’s House Care Partner Exemption Form

To be completed by a referring provider for a client who wishes to stay at Clayton’s House without a Care Partner.

I understand that Dempsey Center’s Clayton’s House Guest Acceptance Policy requires that each patient be accompanied by a care partner to assist the patient as needed to evacuate safely from the building in case of an emergency, secure medical assistance for the patient, and manage daily living tasks.
Patient Name:
As [patient name]'s health care professional, I have assessed the patients and ascertained the following:(Required)
All boxes must be checked to be approved for the Care Partner Exemption
MM slash DD slash YYYY
I understand that while I have provided this judgement, Clayton's House maintains the right to require a care partner, refuse admittance, or to discharge a guest at any time.(Required)
Provider Name(Required)