Boston Request to Stay

HOSPITAL STAFF/SOCIAL WORKERS ONLY

Please complete this form, being sure to include information for all persons requesting to stay.

All those over 18 years of age must have completed answers for the Yes/No questions in section 3.

Stay Request:

Referring Persons Role

* Referring Person Name

* Referring Person Phone

* Referring Person Email

* Check In Date

* Check Out Date

Number of Occupants First Night

Patient Information:

* Patient Name ( First and Last )

* Patient Gender

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

* Patient Ethnicity

* Diagnosis

* Patient is being treated at:

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

* Does the patient have Medicaid?

* Physician/Doctor

Guest Information:

Our goal is to provide a safe & secure environment for all guests. The following questions are required of all adults requesting a stay at the Ronald McDonald House at Boston. Certain situations may require more information. The referring medical professional must provide additional details (at the end of this section) for any 'Yes' or 'Unknown at This Time' answers.

Please note that guest rooms can accommodate a maximum of 5 people (if room occupants are co-sleeping). We understand the importance of having family with us; however, for safety and service reasons, we can not exceed the occupancy limit of the guest rooms.

* Primary Guardian/Caregiver Name

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Email

* Primary Phone Number

I agree to receive texts at this number.

Alternate Phone

I agree to receive texts at this number.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Is this the family's permanent address?

Second Guardian/Caregiver Name (First and Last)

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Primary Phone Number

I agree to receive texts at this number.

* Email

Additional Guests / Family Members: I agree to receive texts at this number.

Add Another Guest

Additional Information:

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

* Has the family stayed with us before?

Yes No

Please make family aware that we ask for a $10 contribution per night to help cover the cost of their stay. Are they able to contribute at this time?

Need Parking Space?

Are both parents over the age of 18?

Does family need housing from 3 to 90 days?

Any safety or social concerns? Drug abuse,child abuse, DCF/DCYF involvement, domestic violence, felonies, etc?

Are you aware of any Infectious/Contagious Diseases in the family?

Will patient stay at Ronald McDonald House?

Is patient 21 or younger? Or High-risk pregnancy?

Will an interpreter be needed?

* Primary Language

Family knows check in is 9-5.

Apartment will be occupied 5 nights/wk.

Any Special Requests/Needs? Disability accessible room? Please detail below.

Upon submission of this form you should receive email confirmation that this form was received. If you do not receive email confirmation- please let us know.

Normally, we will get back to you within 24 hours or the next business day after receiving the form. If you do not hear from us by then-feel free to give us a call at 617-398-6458.