Dempsey Center›Clayton’s House Provider Information + Referral Hub›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)

INFORMATION ABOUT FACILITY MAKING REFERRAL:

Name of Clinical Care Team Member Completing this Form:(Required)
MM slash DD slash YYYY
Address of Referring Entity/Practice Group:(Required)

INFORMATION ABOUT PATIENT BEING REFERRED:

Patient Name:(Required)
MM slash DD slash YYYY
Patient Address:(Required)
If patient doesn’t have email capabilities, please write “N/A”.
Is use of e-mail approved by Patient?(Required)
Are transporation services requested?(Required)
Transportation services include transport to/from Clayton’s House to appointments, to/from Portland Transportation Center and the Dempsey Center.
For patients who qualify, have you completed the Care Partner Exemption Form?

INFORMATION ABOUT PATIENT'S CARE PARTNER:

Request for stay for Care Partner ONLY?
Should patients be treated on an in-patient basis, care partners may request an independent stay at Clayton’s House during the patient’s treatment dates.
Care Partner Address