We are so glad you're here! Please complete the following questions as accurately as possible.

When you finish this form, all adults (18+) must complete a background check to be eligible to stay.


Patient Information

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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

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Guardian/Caregiver Information

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I agree to receive texts at this number.
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Please Enter Your Address Below:
U.S. / Canadian Postal Code lookup


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I agree to receive texts at this number.

Additional Guests

Below please enter the information for any additional guests that will be staying overnight at the House such as siblings, grandparents, aunts, uncles, cousins, etc. Visitors are welcomed during our visiting hours, but do not need to be added to this request unless they are staying overnight. All guests and guardians over the age of 18 are asked to complete a background check prior to staying. 
 
Will there be any additional guests outside of the guardian(s) listed above?
Yes No
Additional Guests / Family Members

Add Another Guest

Additional Information

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Do you or any of your overnight guests use a wheelchair or other mobility device that we should be aware of?
Yes No
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Will you have a vehicle on the premises?

Family Support and Resources
The following questions will help RMHCCIN identify gaps in resources, services, and support. All information will remain confidential.

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Does the patient have Medicaid? (Note this information does not impact your ability to stay and it will not cost you)
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Does the patient have Private Insurance?
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If Private Insurance, who is the patients provider? (Type N/A if you don't have)

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What is your current employment status?

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Do you currently receive any governmental assistance with any of the following?
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Food Stamps (SNAP)
Yes No
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Housing Assistance (Section 8, Public Housing)
Yes No
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Unemployment Benefits
Yes No
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Social Security
Yes No
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Disability Benefits
Yes No
Other (please specify)

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How many people live in your household?

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Have you experienced a recent financial hardship (such as job loss, medical expenses, or other unexpected expenses)?
Yes No

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Do you rent or own your home?

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Are you currently at risk of eviction or losing your housing?
Yes No

Which of the following resources do you or your family have an immediate need for?
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Food and Groceries
Yes No
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Utilities (electricity, water, gas)
Yes No
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Transportation (fuel, public transportation, Lyft)
Yes No
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Health Care/Medical Needs
Yes No
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Personal Care/Hygiene Products
Yes No
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Educational Support (e.g., school supplies)
Yes No
Other (please specify)

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Do you feel you have access to adequate emotional support (e.g., counseling, community resources, or mental health services)?

What type of emotional support do you feel would most benefit you and your family?
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Counseling or Therapy
Yes No
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Peer Support Groups
Yes No
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Stress Management Tools
Yes No
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Mental Health Hotlines
Yes No
Other (please specify)

Are there any other circumstances you would like us to know during your stay with us?