Social Workers must complete all required information prior to submission.
All stay requests must be confirmed by a staff member prior to arrival.

1. Stay Request
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# Occupants First Night
Is the family International or Domestic?
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Have any of the adults been convicted of child abuse or domestic violence or does anyone have an open DCF case?
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Does every adult (18+)member of the family have a photo ID?

2. Patient Information
Additional Patients can be added in the guest information below. Select the relationship patient.
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

Addition Patient Information:

3. Guest Information
Our rooms have a capacity of 3 guests including the patient.
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I agree to receive texts at this number.
Primary Guardian's Address: Enter the zip code in the box below to prefill additional address information.
U.S. / Canadian Postal Code lookup


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I agree to receive texts at this number.



Additional Guests / Family Members

Add Another Guest


4. Additional Information
Please provide any special needs or accommodations
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Will the family have a vehicle?
Has family stayed here before?

5. Insurance Information
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Patient Insurance Member ID: (Use N/A if not applicable)
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Does patient have Medicaid?
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Medicaid State (enter N/A if there is no Medicaid)
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Medicaid Notes


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