Mayo Clinic Social Work Referral

Ronald McDonald House Charities Midwest | MN, WI, IA Referral Form To be completed by Mayo Clinic Social Work Team Member

Mayo ROI completed:

Patient Information:

For unborn patients add the due date as the date of birth.

Additional patients can be added in the section called, Other adults/caregivers/siblings accompanying patient. Choose 'Patient' as the relationship.

* Patient Legal Name

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

* Requested Check In

The family will need translation services at check in?

* Primary Language

Does the family live outside of Olmsted County in Minnesota?

Name of parent, adult guardian, or caregiver:

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Email

* Primary Phone Number

I agree to receive texts at this number.

Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

Primary Phone Number

I agree to receive texts at this number.

*If the parents/guardians of the patient are not in the same household, then a referral is required for each parent/guardian, if they are both planning on staying at RMH.

Have guardians or anyone expected to stay been charged or convicted of crimes that involve assault/violence, domestic violence, child abuse, crimes against children, sex offenses, felony level offenses or the subject of a pending court case?

Is there an open or pending CPS case regarding this family or guardians?

Is anyone actively serving probation or parole sentence?

Social Work Explanations/Concerns/Notes:

Patient has Medicaid

Reimbursement of lodging costs has been requested and/or approved from Medicaid

* Social Worker Name

Completion of this referral does not guarantee lodging at the Ronald McDonald House.