Online Guest Stay Request

ONLINE GUEST REFERRAL FORM

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:



Acceptance

Your request will be processed. Do you want to continue?



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