Online Registration

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

* Patient Name ( First and Last )

* Patient Date of Birth (MM/DD/YYYY)

Patient Gender

* Patient Ethnicity

Patient is being treated at:

Will the patient be inpatient or outpatient?

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

* Department

Diagnosis

Assigned Social Worker / Hospital Staff

Guardian/Caregiver Information

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

* Ethnicity

* Primary Phone Number

* Email

Please Enter Your Address Below:

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Ethnicity

Primary Phone 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

* What is your requested check in date? (Please note that we are unable to guarantee room availability on the requested date).

* What is your estimated check out date?

Will you have a vehicle on the premises?

Car Make/Model/Description

Car License State

License Plate#

Which of these describes your total household income? (Note: This information is only used in securing funding for the House.)

Does the patient have Medicaid? (Note this information does not impact your ability to stay and it will not cost you)

Does the patient have Private Insurance?

* What is the patients Medicaid ID/Private INS. # (Type N/A if you do not have Medicaid or Insurance)

* Medicaid State (Choose N/A if you do not have Medicaid)

If Private Insurance, who is the patients provider? (Type N/A if you don't have)