Online Guest Stay Request

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.



1. Stay Request


2. Patient Information

Patient 1


1. If the 'Facility Treated At' is 'OTHER', please provide location details here.

* 3. Name of Doctor or Medical Professional treating the patient*

4. Name person making this request.

5. Referrer's Contact Phone Number:

* 6. Type of stay being requested?**

7. Additional details of the diagnosis/ a brief description of treatment(s) being received-*



3. Guest Information

Guest 1


* A. Is the patient 18 years of age or younger OR continuing medical care for a previously treated pediatric condition?**

* B. Do both the patient and house guest(s) live outside of Ada County?

* C. Are all adult guests who will be staying at the House able to function independently?

* D. Is the parent or legal guardian of the patient the one requesting this stay or day use?

* E. Does guest have a history of violence or abuse (physical, mental, or sexual)?

* F. Is there a current restraining order against the guest or does the guest have a restraining order/ No Contact Order against another person?

* G. Has guest been in jail or prison within the last 6 years?

* H. Is guest currently on parole or probabtion?

* I. Has guest ever been convicted of charges of a crime against a child or of domestic violence?

* J. Is parental abuse or neglect suspected in the child's injury or illness for which they are receiving treatment?

* K. Does guest have any current involvement with Child Protective Services?

* L. Does any individual requesting to be a guest of the House have a current substance abuse issue, or similar addiction, that could be problemtic for members of the House community?

* M. Has any person, requesting to be a guest, been exposed to a contagious illness within the last 2 weeks?

* N. Is a Parent/ Guardian, of the patient receiving care, under the age of 18 (and requesting to be a guest of the House)?

O. Please explain any 'Yes' or 'Unknown at This Time' answers in this section (the previous 10 questions).

* P. I AM EITHER AN ADULT REQUESTING TO BE A GUEST AT THE IDAHO RMH OR A REFERRING MEDICAL PROFESSIONAL. I ATTEST THAT I HAVE REVIEWED THESE REFERRAL CRITERIA QUESTIONS FULLY WITH ALL ADULTS INTERESTED IN ACCOMMODATION AT THE IDAHO RONALD MCDONALD HOUSE & ALL POTENTIAL ADULT GUESTS UNDERSTAND THAT THEY WILL BE REQUIRED TO SIGN THE ABOVE REFERRAL CRITERIA, UPON CHECK-IN, IF ACCOMMODATION IS PROVIDED BY RMHC OF ID.



4. Additional Information

* 1. Is English the primary language in the home?

2. If no, what is the primary language?

3. Please select any of the options below that are applicable for the guest family.

4. If 'OTHER' was selected, provide additional details in the text box below.

5. Please provide information (Name, Date of Birth, Additional Patient or Guest, Diagnosis (if patient), Relationship to Patient (if Guest), etc) of any additional people that could not be added to this form above.


Notes regarding this request:




Confirmation

By selecting yes, you are agreeing to all of the above.

To confirm a room, please call 24-hours before your requested stay date.  Family Sevices 208-336-5478

 



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