Please select your preferred stay location (Boston or Providence) from the tabs at the top *******Guest Stay Request for Social Workers/Referrers********

1. Stay Request

2. Patient Information

* Patient's Age
Please provide a brief description of the patient's diagnosis/treatment:
* Referring Persons Role
* Referring Person Name
* Referring Person Phone
* Referring Person Email
* Name of Doctor or Medical Professional

3. Guest Information

Contact Information

* Is the address provided the families permanent address?
* Has This Family Stayed Here Before?
* Name of Emergency Contact for Parent
* Phone of Emergency Contact for Parent
* Need Parking Space?
* Any Special Requests/Needs? Disability accessible room? Please detail below

4. Additional Information

Please make family aware that we ask for a $10 contribution per night to help cover the cost of their stay. Are they able to contribute at this time?
* Are both parents over 18 yrs?
* Does family need housing from 3 to 90 days? If No, please call us for consideration of a different stay length.
* Any safety or social concerns? Drug abuse,child abuse, DCF/DCYF involvement, domestic violence, felonies, etc? If so, Please call RMHC to discuss.
* Are you aware of any Infectious/Contagious Diseases in the family? If so, contact us.
* Is Patient Staying in RMHC housing?
* Is patient 21 or younger? Or High-risk pregnancy?
* Is an Interpreter Needed? Note that interpreters are required for checkins and checkouts and 24/7, and provided by the hospital
* Family knows check in is 9-5
* Apartment will be occupied 5 nights/wk
* Caregiver can care for themself and Patient Independently

Notes for this request: Only 1 parking space is available per apartment

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


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