For Hospital Staff to Complete and Submit

1. Stay Request

2. Patient Information

* On what unit is patient staying

3. Guest Information

Contact Information

* Will they have transportation

4. Additional Information

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

Notes regarding this request:

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