Home / Refer A Family – Form / Roanoke House Referral Form

To continue ensuring the safety and well-being of all the families we serve, we are adhering to similar guest restrictions as implemented by our hospital partners. For this reason, we are not able to welcome siblings into the House at this time. For specific questions regarding this policy, please contact a Guest Services team member at (602) 264-2654.

Roanoke House Referral Form

    Attention Referring Professional: Please meet with each family prior to referring. The patient's permanent residence must be at least 30 miles from RMHC of Central and Northern Arizona (exceptions allowed on a case by case basis depending on census and patient diagnosis). If you have questions regarding the appropriateness of a family contact a RMHC staff member at 602-264-2654.

    All admissions to any of the three Valley Houses are based on availability.

    Referral Intended for Roanoke House

    Referral Source Information

    E-mail confirmation will be sent on all referrals.

    Patient's Information

    Family only eligible if patient has NOT reached 22nd birthday
    Patient Diagnosis Department (please select from dropdown menu)




    Appointment Information

    If patient is in-patient, include discharge date

    Guest's information





    No one under 18 may stay at the House without a parent/legal guardian.


    Has Guest 1 received the COVID-19 vaccine?

    Has Guest 2 received the COVID-19 vaccine?

    Has Guest 3 received the COVID-19 vaccine?

    Has Guest 4 received the COVID-19 vaccine?



    Other Information






    Infectious Disease Prevention Regarding the Coronavirus









    Billing Information

    The following are the only insurance companies RMHC can bill directly: AHCCCS; Bone Marrow Transplant; CRS; Nick & Kelly Hart; Presbyterian Salud

    By submitting this form the referring professional accepts responsibility for understanding the Ronald McDonald House Occupancy and Room Request Guidelines and has confirmed that this family meets the requirements for temporary lodging at RMHC Phoenix. All requests will be placed on the Waiting List in the order received. RMHC cannot guarantee a room.

    If you have any questions regarding the appropriateness of a family please feel free to contact a staff member at 602-264-2654