Registration - Social Worker Form

This form must be filled out by medical staff only.

All families referred to Houses operated by the Ronald McDonald House Missoula must meet the minimum eligibility requirements:

To stay at the Ronald McDonald House Missoula, guests must:

Consent to and pass a background check. Families must have a child under 21 receiving medical treatment in Missoula or a high-risk pregnancy requiring proximity to a medical facility.
Adult patients and their families are not eligible to stay.
Guests must be 18 or older to register. Those under 18 must be accompanied by an immediate family member or spouse aged 18+ who will sign the release form.

Admissions/Referrals:

Rooms are assigned on a first-come, first-serve basis, with referrals required from healthcare providers or hospital social workers. All referrals must pass a criminal background check.
Referrals are not accepted for individuals with a criminal history in the past five years or suspected of domestic violence, drug/alcohol abuse, or sexual abuse.
Referrals must be submitted at least 24 hours before check-in.
If no rooms are available, families will be added to a waiting list. Guests must use their room daily or arrange with Ronald McDonald House if leaving for more than 24 hours.
Guests with contagious or communicable diseases will not be permitted.
There is no fee to stay, but a $25 per night donation is suggested. Ronald McDonald House will not turn anyone away due to inability to pay. Medicaid patients must arrange pre-authorization for reimbursement if applicable.
Check-in is 9 a.m.–5 p.m. unless prearranged.

Referring Staff Information

* Social Worker/Medical Staff Name

* Phone

Patient Appointment & Medical Information

* Anticipated Check In Date:

* Estimated Check Out Day:

Appointment Date (if applicable):

Appointment Time:

* Patient is being treated at:

* Diagnosis:

Gestational Age (if applicable):

Patient Information:

* Patient Name ( First and Last )

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

Patient Social Security Number (confidential — used only for required background screening)

Phone Number

I agree to receive texts at this number.

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

Zip

* Patient Gender

* Patient Ethnicity

* Reason For Stay:

Physician/Doctor

Medicaid Id

* Medicaid ID (Type "N/A" if no Medicaid)

Additional information/notes:

Guardian Information

Parent/Guardian 1

* Guardian/Caregiver Name (First and Last)

Relationship to patient

* Primary Phone Number

I agree to receive texts at this number.

* Date of Birth (MM/DD/YYYY)

Guardian/Caregiver 1 Social Security Number (confidential — used only for required background screening)

* Guardian/Caregiver Gender

* Guardian Email

Guardian/Caregiver 2

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

* Primary Phone Number

I agree to receive texts at this number.

* Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

Guardian/Caregiver 2 Social Security Number (confidential — used only for required background screening)

Occupancy & Stay Details

Our rooms can accomodate up four people per night.

Total number of adults staying:

Total number of siblings staying:

Are guests/patients able to use stairs?

Note: We do not have an elevator, but a chair lift is available. While we cannot always guarantee a downstairs room, this information helps us prioritize accommodations.

Any other special accommodations or other information we should know?:

Family verbally consented to background check