Clayton's House Referral Form | Cancer Care & Support

Dempsey Center›Clayton’s House Registration Forms›Clayton’s House Referral Form

Clayton's House Referral Form for Application for Stay

For completion by a clinical team member from the patients treating HealthCare Provider

The Dempsey Center offers programming in Lewiston & South Portland, Maine and online at Dempsey Connects. We offer a haven of support for those traveling for cancer treatment at our hospitality home, Clayton’s House, in Portland, Maine. There is no cost for qualifying patients, to stay at Clayton’s House.

By signing below, I am representing that I am a member of the clinical care team - to the patient identified below. I am recommending the patient for a stay at Clayton’s House, and I am certifying that the patient meets the following eligibility criteria:(Required)

the Patient is undergoing or is being scheduled to undergo a procedure or treatment for cancer such as chemotherapy, radiation and/or having exploratory or other cancer-related surgery;

the Patient is 18 years of age or older;

the Patient lives in stable housing more than 30 miles away from the Portland, Maine area cancer treatment facility where the Patient is and/or will be receiving cancer treatment;

the Patient does not have a communicable, infectious disease that could place other Clayton’s House patrons at risk;

the Patient understands the terms of stay and is recommended to stay in a shared living space;

the Patient has consented to this referral, and to communications with Dempsey Centers and/or Clayton’s House for the purpose of applying for a stay at Clayton’s House.

INFORMATION ABOUT FACILITY MAKING REFERRAL:

Name of Clinical Care Team Member:(Required)

Prefix First Last Suffix

Referring Treatment Facility:(Required)

Phone(Required)

Email(Required)

Date of Submission of this Referral:

Contact Information for Referring Provider:(Required)

Name of Referring Entity/Practice Group:(Required)

Address of Referring Entity/Practice Group:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

INFORMATION ABOUT PATIENT BEING REFERRED:

Patient Name:(Required)

First Last

Date of Birth(Required)

Patient Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:(Required)

OK to leave message?(Required)

Email(Required)

Is use of e-mail approved by Patient?(Required)

Yes

Dates & Times of Relevant Appointments:(Required)

Clayton's House Referral Form for Application for Stay

INFORMATION ABOUT FACILITY MAKING REFERRAL:

INFORMATION ABOUT PATIENT BEING REFERRED:

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