Request for Room

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 Name:

Hospital Staff Title or Position:

* Hospital Staff Phone:

* Facility:

* Patient Name ( First and Last )

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

* Patient Gender

* Stay Type

* Patient Diagnosis:

* Unit/OP Clinic:

* Medicaid State

* Medicaid ID (if patient does not have Medicaid, please type N/A. DO NOT ENTER RANDOM NUMBERS)

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

Date of Birth (MM/DD/YYYY)

* Primary Phone Number

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

* Date Lodging Needed:

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: