Referral Form

Our guest referral form (a pdf) is designed to be completed by a social worker or healthcare provider. Below the referral form you can also use that link  to download our brochure.

Download form button

download button

Please advise patients and families that a referral does not guarantee a room. The person requesting lodging will be contacted upon receipt of the form for additional information and to confirm the reservation.

Once the form is completed, it can be faxed to 801-788-5264 or submitted via email to

If you are unable to open the document have questions about the form or making a referral, feel free to contact us.