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
* Name of Doctor or Medical Professional
* Referring Persons Role
* Referring Person Name
* Referring Person Phone
* Referring Person Email

3. Guest Information

Contact Information

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

4. Additional Information

* Is the family aware that our check in time is between 9am and 8pm?
* Please make family aware that we ask for a $10 fee 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

Notes regarding this request:

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


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