Referral Form

Please check all boxes to indicate that you have read the following: *

I understand that Molly’s House cannot accept guests who are homeless or without a permanent address. This policy is in place to protect the integrity of the mission and the intended use of the house. I agree to refrain from submitting a referral for those who are homeless or for patients who do not have a place to go after discharge. I understand that there is a $40 per night, per room, charge, and I agree to communicate this to the guests before making a referral. I understand that a patient receiving outpatient medical treatment may stay at Molly’s House for up to 90 days. Patients requiring assistance must have a caregiver with them during their stay at Molly’s House. I agree to send an updated referral after 90 days if a longer stay is requested. I understand that the staff and volunteers of Molly’s House cannot provide physical assistance or medically related services of any kind. A visiting medical professional may come to Molly’s House to check on their patient and perform necessary outpatient therapy/rehabilitation services. I agree to communicate this to the guests before making a referral. I understand that Molly’s House cannot provide accommodations for patients receiving hospice care or for patients no longer receiving ongoing medical treatment. I agree to notify Molly’s House if a patient staying at Molly’s House no longer qualifies to stay based on these conditions. I understand that Molly’s House can also accommodate family & friends visiting a loved one who is a patient in the hospital, medical facility, or in hospice care. Family and friends of a patient may reserve 1 room and stay for up to 30 days. I agree to send an updated referral after 30 days if a longer stay is requested.

​REFERRAL FORM

REFERRAL FORM