Referral Form for SECU Family House

The following form is to be filled out by UNC Hospital Staff. Please take the time to fill out all information fully and correctly to make the process efficient. Contact us at admissions@secufh.org or 919-932-8000 if there are any questions.

Patient Information
Patient's age 18 and older are elgible to stay at SECU Family House.
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I agree to receive texts at this number.
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If there is no email to contact the patient with, please put in "admissions@secufh.org" so that we know we need to reach out to the patient/family.
Patient Address
U.S. / Canadian Postal Code lookup


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Caregiver Information
If there is no Caregiver/Additional Guest, please move on to "Stay Information"
I agree to receive texts at this number.
U.S. / Canadian Postal Code lookup



Additional Guests / Family Members

Add Another Guest

STAY INFORMATION
We understand that dates may be unknown at this time. Please pick the best approximate and we will communicate with the patient/guests about what is needed.
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

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Has Anyone Stayed at the SECU Family House at UNC Hospitals Before?
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At the SECU Family House, a regular room is $54/night and a suite (for transplant patients) is $72/night. Please select the rate that best applies to this upcoming stay.
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Any notes that you think would be helpful for the SECU Family House to know?

Hospital Information
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