Welcome


* I understand that RMHC-KC cannot guarantee rooms as availability changes on a daily basis. Families should call 816-541-8460 the day of your requested check-in date to see if we have availability.
* The patient receiving evaluation and/or treatment is 21 years of age or younger?
* Do any members of the guest party have symptoms related to contagious illnesses?
* Does anyone in the guest party have a pending child abuse investigation or open CA/N case?
* Does anyone in the guest party have an assault related or sex related crime?
* Does anyone in the guest party have any felony charges or convictions?
* Has family stayed at RMHC-KC previously?

Patient Information


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* Does the patient have Mediciad?
Medicaid if yes, brief description of what patient is being seen for
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

* If out-patient: Date of last appointment at hospital (MM/DD/YYYY)
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Add name of Social Worker here if other was chosen:

Patient's Primary Address

U.S. / Canadian Postal Code lookup


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Contact Information


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* Guardian Phone

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Guests

Additional Guests / Family Members

Add Another Guest

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.
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Additional Information

Family’s method of transportation to the hospital or our house?
Will you have a vehicle on premises?
* Has anyone in the guest party been asked to self-quarantine due to COVID-19 in the past 10 days?
* In the last 48 hours, has anyone in the guest party had: cough, shortness of breath, difficulty breathing, new loss of smell/ taste, sore throat, runny nose/ congestion and/or GI symptoms?
* In the last 48 hours, has anyone in the guest party had: a fever of 100.0 degrees fahrenheit or higher, body aches, and/ or headache?
* Is anyone in the guest party waiting on a COVID test result not related to preadmission testing for the patient?
* Has anyone in the guest party had a positive COVID test in the last 10 days?
* Does anyone in the guest party need a wheelchair accessible room?
* Is there any additional information you would like to add?