Patient must be 21 years of age or under, or an expectant mother.
Guests staying in the house must be 18 years of age or have a parent/legal guardian with them at all times.

A referral does not guarantee a room.
We operate on a first come, first serve basis until the house is a full.
When the House is full, we will have a wait list, the family will be contacted when a room is available.

*
* Hospital Staff Title or Position:
*
*

*
*
*
*
*
*
*
*

*
*
*

U.S. / Canadian Postal Code lookup


*
*

*


* Is this a high risk pregnancy?
* Is there any reason the family would not be appropriate for the RMH?
* CPS current investigation or previous conviction?
* Pest infestation?
* Convicted Sex offender?
* Convicted violent offender?

* Is referral is from NTU or Lilly’s Place?
Did mother have a positive drug screen for any substance that was not prescribed to her?
If answer is no, skip ahead to "Special Needs/Notes".
Is mother in a drug recovery program?
If yes, Name of program:
Length of time in drug recovery program:

Special needs/Notes: