Request a Room Form

 
You can request a room at the RMHC Richmond online. A staff member at RMHC Richmond will contact you to complete your request. Please call 804-355-6517 if you have not heard from a staff member within 2 hours of completing this request.
Guest Stay Request


Stay Request
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# Occupants First Night

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


All Guest Information
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I agree to receive texts at this number.


Family is currently unhoused.
Mailing Address
U.S. / Canadian Postal Code lookup




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I agree to receive texts at this number.


Additional Guests / Family Members

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Add Another Guest

More Guest and Referring Partner Information
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Does anyone in the family have phyical limitations?
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Does the family have thier own transportation? 
Yes No
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Referring Partner Unit
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Referring Partner Name
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Referring Partner Position
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Referring Partner Phone Number
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Referring Partner Email
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Family has given permission to share their information
Yes No