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

Service Provider *

Wake Forest Baptist Health/Comprehensive Cancer Center

Novant Health Forsyth Medical Center/Derrick Davis Cancer Ctr

Other

Referred by (name): *

Unit Location:

Phone Number *

Email *

Patient Name *

Patient Date of Birth (MM/DD/YYYY) *

Patient County of Residence *

Service Line *

Cancer

Heart

Surgical

Medical

Neuro

Burn

Trauma

Stem/BM Transplant

Solid Organ Transplant

Other

Patient will receive treatment as *

Inpatient

Outpatient

If inpatient, is the caregiver allowed to visit?

Yes

No

Is the Patient in the ICU? *

Yes

No

Caregiver Primary Contact Name *

Relationship to Patient *

Requested Arrival Date *

Estimated Length of Stay *

Cell Phone Number: *

Email *

Alternate Phone Number

Today's Date

Additional Helpful Information

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