For Families

Online Apartment Referral Form

To be completed and submitted by social workers only. Please provide all information requested.

Social Worker
Social Worker Phone
Social Worker Email		(leave empty if unavailble)
Hospital
Department
Patient Name
Patient's Address (Please include street address, city, state & zip)
Proof of Residence		Proof of residence (a utility bill, not telephone) may be faxed to Resident Manager-West at 314.531.6353
Insurance or Lodging Reimbursement
Case Manager
Case Manager Phone
Case Manager Email		(leave empty if unavailble)
First Day of Need
Treatment
Immunosuppressed – currently or in the future? Yes No
Special Considerations
By submitting this form the requesting social worker confirms that he/she has reviewed the Apartment Procedures, completed the apartment orientation by RMH Staff and have determined that the above family meets the qualifications set forth by the RMH. Upon receiving this referral, House Management will review the family’s status and determine if they are appropriate for an apartment. *If you have any questions or concerns, please call Resident Manger 314.531.6601, Ext. 204.*