Hubbert Homes | Sober Living in Oakland, CA

Step 1 of 5

Select a Service

Choose the appropriate Community Support service for your member. Both require KP Medi-Cal membership.

KP Medi-Cal Membership Confirmation

Is this member a Kaiser Permanente Medi-Cal Member? *

Yes — This is a KP Medi-Cal Member

No — Stop. Please send referral to their assigned Medi-Cal Managed Care Plan.

Which Service Does This Member Need?

🏥

Medical Respite
(Recuperative Care)

Faraji House

Alameda County Only

🏠

Short-Term Post-Hospitalization Housing

Hubbert Homes

Alameda & Santa Clara Counties

Step 2 of 5 · Section A

Referrer Information

Tell us about yourself and your organization. All fields marked * are required.

Your Details

Date of Referral *

Required

Your Full Name *

Required

Organization Name *

Required

Organization NPI *

Required

Your Role / Title

Organization Address *

Required

Your Email *

Required

Your Phone Number *

Required

Referrer Relationship & Type

Your relationship to the member *

Medical Provider

Social Services Provider

Member / Family

External referral type *

Required

Step 3 of 5 · Section A

Member Information

Member Demographics

Member Full Name * (First, Middle Initial, Last)

Required

Date of Birth *

Required

Phone Number *

Required

Mailing Address * (use shelter/last known if unhoused)

Required

KP Medical Record Number (MRN) *

Required

Medi-Cal CIN (if MRN unknown)

Caregiver / Support Person (Optional)

Caregiver Name

Caregiver Contact (Email or Phone)

Housing Status Attestation *

Required Confirmation

Member meets the HUD definition of homeless OR at risk of homelessness
Supporting documentation can be provided if requested

Member's Housing Status *

Homeless — Meets HUD definition of homelessness

At-risk of homelessness — Meets HUD definition of at-risk

Required

Step 5 of 5

Review & Submit

Review all information before submitting. The completed referral form will be emailed to KP Northern California automatically.

Final Attestation *

I confirm that the member meets the HUD definition of homeless or at risk of homelessness and can provide supporting documentation if requested.

I confirm that all information on this form is accurate and verified, and that the member has consented to participate in the program(s) to which they are being referred.

Where This Referral Goes

Completed referral form will be emailed to [email protected] (KP Northern California)
A copy will be sent to Faraji House for coordination and placement

✅

Referral Submitted Successfully

The completed KP Community Supports referral form has been filled and emailed to KP Northern California. Faraji House will follow up within 1 business day to confirm bed availability and next steps.

Cannot Proceed

Required Confirmation

Medical Respite — Both Criteria Required

Short-Term Post-Hospitalization — All Four Criteria Required

Where This Referral Goes