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