Online Guest Stay Request - Molly's House

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Request to Stay

Thank you for completing your request to stay with us. Before you submit your application, please carefully review the following requirements to ensure your request is not delayed:

Each family must submit an online request form for current and future stays.

Every request must be verified by a staff member from the treating medical facility. Our team will reach out directly to the treatment representative that you list and provide on this form. Submitting an application does not guarantee a room. Please allow 3-4 business days for us to review your application.

Please call Mollys House if your request is urgent- (772) 223-6659.

Submittal of request does not guarantee or hold a room. You must provide a photo ID, complete registration/orientation process, and agree to Conditions of Stay.

All demographic and household income questions help our organization improve our services and provide essential reporting data for securing funds that sustain our program. This data is never reported in ways that are personally indefinable, nor is it used to determine eligibility for our services.

Household is defined as all those who live in the same dwelling as the patient as their primary residence.

1. Stay Request

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

* Where does the patient normally reside?

Request completed by

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

* Diagnosis

* Facility Treated At

* Inpatient/Hospitalized - OR - Outpatient/Staying at Molly's House

* Have you stayed with us before?

Yes

No

* Representative Name

* Representative Contact Information

Add Another Patient

3. Guest Information

If the patient is the only person staying at Molly's House, please input the patient information, otherwise, kindly complete information for each guest that will be staying at Molly's House.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

*Relationship to Patient

Contact Information

* Email

* Mobile Phone

By providing your mobile number, please accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on this number

* Country

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

County

Add Another Guest

4. Additional Information

* Medical Facility Representative

* Facility Representative Contact Information

* Have you applied for medical lodging/housing financial assistance?

* Primary Guest Household Size

* Primary Guest Annual Household Income

Notes regarding this request:

Acceptance

Your request will be processed. Do you want to continue?

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Phone: (772) 223-6659

Molly's House

430 SE Osceola Street, Stuart, FL 34994

Email: info@mollyshouse.org

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Request to Stay

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