Red Mountain Grace
Medical Professional Referral Form
Social Worker Information
Please input your information in the fields below
Social Worker First Name
Social Worker Last Name
Phone Number
Email Address
Health Care Facility Information
Please input information for the hospital or healthcare facility making the referral
Referring Physician First Name
Referring Physician Last Name
Hospital
Please select...
UAB Hospital
St. Vincents Hospital
Children's Hospital
Brookwood Hospital
Grandview
Other
If other, please specify
Patient Information
Please input information for the patient to whom you are making the referral for
First Name
Last Name
Patient Date of Birth
Reason in need of local lodging
Please select...
Bone Marrow Transplant
Cancer Treatment
COVID-19
Heart Transplant
LVAD
Lung Transplant
Pediatric Care
Proton Therapy
Trauma
Other
If other, please specify
Will the patient have additional caregiver(s) staying in Birmingham during their treatment?
Yes
No
Caregiver Information
Please enter the information of the person considered the primary caretaker for the patient below
First Name
Last Name
Relationship to Patient
Additional Information
Can the family accommodate stairs?
Yes
No
Date Family is In Need of Lodging:
Estimated Length of Stay
Other than the patient, how many people will be staying in the apartment?
Please select...
1
2
3
4
5
Any other relevant information that Red Mountain Grace should be aware of as we serve this family:
Contact Information