Ulman House Patient Referral

Patient Qualifications

Please review our qualifications to stay at Ulman House and ensure that your patient qualifies. This referral is not a guarantee that they will have housing, but we will follow up with the patient/caregiver to confirm.

1. Patient has a cancer diagnosis (YES/NO)? *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

2. Patient meets all the following requirements: *This question is required.

Patient is in active cancer treatment
Patient has a permanent address that is more than 35 miles away from treatment facility*
-*If receiving transplant, no mileage requirement
Patient is between the ages of 15 and 39
Patient will have a 24/7 caregiver with them throughout the duration of their stay

3. Patient does not meet all requirements and here is why:

4. I have mentioned to the patient and family that they will need to undergo a background check. (please mention prior to submitting referral) *This question is required.