Referral Form Online

Guest Evaluation Form

This form is to be completed by a social worker, case manager, charge nurse, physician, etc. from the facility referring a guest to MCLH. If MCLH knows far enough in advance of check-in, MCLH staff will contact the guest by phone or letter with information about the house.

1.The room fee is $50 per night.
2.Immediate family and caregivers are welcome.
3.The rooms will accommodate a total of 4 guests, children included. Additional rooms will be necessary for more than 4 guests.
4.There are no roll-a-way beds. There are no baby beds.
5.Absolutely no smoking inside or within 50 feet of the building.
6.Proof of identity is required for all adult guests staying in a room.
7.We are not a “medical” facility and cannot provide medical attention, nursing or personal care.
8.Infusion fluids (iv fluids), colostomy supplies, portable potty chairs, etc. pose biohazard situations and are not allowed.