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Family House Referral Form

Please Note: This form must be completed by a medical center or provider staff member. Once you submit, the form is sent automatically to SECU Family House by e-mail.  

SECU Family House Eligibility Requirements (updated 6/2/2020):

  • Patient must be 18 years of age or older.
  • Patient and caregiver must both have a permanent residence outside Forsyth County, NC.
  • Two caregivers may be referred for an admitted patient only if they are allowed to visit. Special consideration or circumstances should be added below.
  • Referred patients with an active outpatient treatment plan may have 1 caregiver with them.
  • Referred guests are asked to pay a nightly fee of $40. Financial Assistance may be available for a reduced rate and will be determined by our staff.
  • We allow one room per patient with up to two people. Rooms feature two queen beds and a private bath
Referral Form
If inpatient, is the caregiver allowed to visit?
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SECU Family House Winston-Salem
1970 Baldwin Lane
Winston-Salem, NC 27103
info@familyhousews.org
336-793-2822
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