For Hospital Staff to Complete and Submit

1. Stay Request

2. Patient Information

* On what unit is patient staying

3. Guest Information

* Will they have transportation

4. Additional Information

* A. Is the patient 21 years or younger?
* B. Is the parent or legal guardian at least 18 years of age?
* C. Has anyone in the group had any recent exposure to chicken pox, hepatitis, strep throat, measles, or other contagious disease?
* D. Does the family have any concerns of social significance to the House, such as domestic violence, restraining orders, probation, psychiatric disorders, etc.?
* E. Is there current concern for alcohol and/or substance abuse?
* F. Has the family exhibited any behavior that is not appropriate to the House (violence, threatening behavior, non compliance to the hospital rules)?
* G. Is the family currently being investigated by the Department of Family Services?
* H. Is everyone in the family current with inoculations?
* I. If the patient is staying at RMH, will they have medical equipment?
* J. Can the family pay the requested donation of $10 per night?
* Referred by
* Referrer's Contact Information

Notes regarding this request:

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