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)

* Stay Type

* Patient Diagnosis:

* Unit/OP Clinic:

* Medicaid Branch ID

* 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

* Email

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

* Date Lodging Needed:

Additional Guests / Family Members: Add Another Guest

* 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?

Is mother in a drug recovery program?

If yes, Name of program:

Length of time in drug recovery program:

Special needs/Notes: