Application for Housing

This housing application is for IU Health patients (IU Simon Cancer Center / University and Methodist Hospitals) only for our downtown housing locations. It is a good idea to contact your social worker or transplant coordinator for a housing referral since it is required for all downtown applications. Patients and families at Franciscan Health should contact their social worker for a southside housing application. For information about housing for patients at other hospitals, email info@fairhavenfoundation.org.

Have you been served at Fair Haven before?

Application For:

Overnight Lodging

Minimum number of separate beds requested: (subject to availability)

Shower and Laundry Only

If you selected Overnight Lodging, please complete the Start and End Dates below.

Estimated Start Date of Overnight Lodging

Estimated End Date of Overnight Lodging

If you selected Shower and Laundry Only, please complete the Date and Time below.

Requested Date

Requested Time

* Patient Name ( First and Last )

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Email Address

* Diagnosis

* Treatment

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

* Patient is being treated at:

Will the patient be inpatient or outpatient?

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

Assigned Social Worker / Hospital Staff or Physician

Please complete the following section. If there will not be a caregiver, please use the patient's information.

Caregiver's Name

Date of Birth (MM/DD/YYYY)

Relationship to patient

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

Zip

Additional Guests / Family Members: Add Another Guest

Caregiver's Email

Patient Phone

I agree to receive texts at this number.

Caregiver's Phone

I agree to receive texts at this number.

Emergency / Additional Phone

Emergency / Additional Contact name

Does anyone who will be staying at one of our facilities smoke? (This will not affect the status of your application.)

Yes No

Is vehicle parking needed?

Yes No

Comments / Additional Needs

By checking this box, I grant permission for health care professionals to release information including my name, my family’s and caregiver’s names, and medical information to Fair Haven staff and volunteers for the purpose of applying for housing and/or other assistance. I authorize Fair Haven and/or Core Redevelopment, LLC to perform a criminal background check(s) on all guests applying for housing.

By checking this box, all guests agree to NO SMOKING, NO PETS, NO ILLEGAL SUBSTANCES in any of our facilities at any time. I understand that if I fail to comply with these rules I may be required to vacate the premises. If provided with housing, I grant Fair Haven permission to use information about me and my family for the purpose of supporting this cause as a nonprofit organization.