Returning Guest Application
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.
Application For:
Overnight Lodging
Minimum number of separate beds requested: (subject to availability)
Please select a response
1
2
3
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 )
Phone Number
I agree to receive texts at this number.
*
Diagnosis
*
Reason For Stay
Allogeneic Bone Marrow/Cord/Stem Cell Transplant-CA
Autologous Stem Cell Transplant-CA
Burn Unit
CAR T-Cell Therapy
Cardiovascular Critical Care
Chemotherapy-CA
Clinical/Drug Trial
COLTT
Critical Care/ICU
Emergency Medicine (Injury/Trauma/Accident)
Evaluation
Heart Transplant
High Risk Pregnancy
Intestine Transplant
Kidney & Pancreas Transplant
Kidney Transplant
Liver Transplant
Lung Transplant
Multivisceral Transplant
Neurology
Other
Other Organ Transplant
Palliative Care
Pancreas Transplant
Photopheresis
Population Health
Radiation and Chemotherapy-CA
Radiation-CA
Rehabilitation
Sleep Lab
Stem Cell Collection
Surgery
Ventricular Assistive Device
*
Patient Date of Birth (MM/DD/YYYY)
*
Patient is being treated at:
IU Simon Cancer Center
IU Health Methodist Hospital
IU Health University Hospital
Riley Children's Hospital
Ascension
Central Indiana Cancer Center- IUH
Community
Eskenazi
Franciscan
IU Health North /Schwarz Cancer Center
IU Health Physicians
IU Health West
IU Health- Carmel
Long Term Care
Other
Will the patient be inpatient or outpatient?
Inpatient - Hospitalized
Outpatient - Non-Hospitalized
Both, during this stay.
*
Caregiver's Name
*
Date of Birth (MM/DD/YYYY)
Additional Guests / Family Members
Add Another Guest
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.
Help Request Sent
Ok
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit
