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RMHC will verify appointment/treatment dates with the hospital. Please enter the date/time of first appointment or hospital admittance.
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Inpatient - Hospitalized
  Outpatient - Non-Hospitalized
  Both, during this stay.
*Inpatient refers to Hospitalized patients. Outpatient refers to Non-Hospitalized patients.
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Do you consent to Family Placement contacting you via text? (message and data rates may apply)
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Second Guardian Information (Optional)
Do you consent to Family Placement contacting you via text? (message and data rates may apply)
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Additional Guests / Family Members
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Add Another Guest
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Will you be parking a car with us during your stay?
Please fill out the vehicle information below.
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No
  Yes
Does the family require an ADA Room?We will do our best to accomodate, this is not guaranteed. Please reach out to family placement to check on availability after you submit your request. Family@rmhcoregon.org.
Does the family require a room with a kitchen? (Only applies for East House Location and is prioritized for patients who are immunocompromised)We will do our best to accomodate, this is not guaranteed. Please reach out to family placement to check on availability after you submit your request. Family@rmhcoregon.org.
If OHSU South Waterfront House is full, would you like to be considered for a room at our East House located at 2620 N Commercial Ave? This location is a 15 min drive from OHSU.