FAMILY HOUSE REFERRAL

Please Note: This form must be completed by a medical center or provider staff member. Once you submit, the form is sent automatically to SECU Family House.

SECU Family House Eligibility Requirements:

Patient must be 18 years of age or older.
Guests must have a permanent residence outside Forsyth County, NC.
Referred guests are asked to pay a nightly fee of $40. Financial Assistance may be available for a reduced rate and will be determined by our staff.
We allow one room per patient with up to four people. Rooms feature two queen beds and a private bath.

* Service Provider:

* Referred by (name):

Unit Location:

* Phone Number:

* Email:

* Patient Name:

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

* Phone Number

I agree to receive texts at this number.

Patient's Phyical Address:

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

* Service Line:

* Patient will receive treatment as:

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

Is the Patient in the ICU?:

If inpatient, is the caregiver allowed to visit?:

Caregiver Name (primary contact for the stay)

Caregiver Phone

I agree to receive texts at this number.

Caregiver Relationship

* Requested Arrival Date:

* Estimated Check Out Date:

Language Spoken by Primary Contact

Payment Type

Additional Helpful Information: