Online Guest Stay Request - Molly's House

Request to Stay

Request to Stay

Please allow up to 5 business days for our team to review your submission and contact you.

All stay requests must be verified by a staff member from the treating medical facility. Our team may contact the medical office to confirm the patient's treatment schedule, appointment information, or plan of care.

To ensure your reservation remains active, guests must remain responsive to communication from our team prior to arrival. Reservations may be canceled if we are unable to confirm details or reach the guest before their scheduled stay.

Please note: A new Request to Stay form must be submitted for each stay, including repeat visits and returning guests.

If your need is urgent, please contact Molly's House directly at (772) 223-6659.

1. Stay Request

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

* Where does the patient normally reside?

Request completed by

2. Patient Information

* First Name

Middle Name

* Last Name

* Date of Birth

* Diagnosis

* Treating Medical Facility

* Inpatient/Hospitalized - OR - Outpatient/Staying at Molly's House

* Please provide a staff member who we may contact to confirm the patient's care plan or apt. schedule. This may be a nurse navigator, social worker, case manager, physician's office staff member, etc.

* Staff's email or phone number

* Is your stay cancer-related? Please select YES if the patient's stay is related to cancer care, including screening, diagnostic testing, treatment, follow-up appointments, clinical trials, or monitoring related to cancer.

Yes

Have you applied for medical lodging/housing financial assistance?

Yes

Please write the foundation name

* Have you stayed with us before?

Yes

Add Another Patient

3. Guest Information

If the patient is the only person staying at Molly's House, please input the patient information, otherwise, kindly complete information for each guest that will be staying at Molly's House.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

*Relationship to Patient

Contact Information

* Email

*Mobile Phone

By checking this box I agree to receive transactional/informational SMS communications from Molly's House. Messages frequency may vary. Message and data rates may apply. Reply HELP for help or STOP to opt-out. I also accept Terms of Service and Privacy Policy.

* Country

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

County

Add Another Guest

Notes regarding this request:

Acceptance

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

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A welcoming home for patients and families during medical care.

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Contact Information

info@mollyshouse.org
(772) 223-6659 (phone)
(772) 223-9990 (fax)
430 SE Osceola Street,
Stuart, FL 34994, United States

Molly's House is a charitable 501(c)(3) organization (EIN 65-0407242). Your contribution is completely tax-deductible to the fullest extent of the law.

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