Application for unit use at Boston CH
This is a form to apply to stay at Christopher's Haven, Boston. Please do not hesitate to contact Catie MacWilliams, the Family Services Manager, at catiemacwilliams@christophershaven.org or (857) 233-4178 with any and all questions.
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Full Name and Birthdate of Child Receiving Treatment: *
Parent/Legal Guardian 1 Full Name and Pronouns: *
Email Address: *
Cell Phone Number: *
Address (Including city, state, postal code, and country): *
Parent/Legal Guardian's 2 Full Name and Pronouns: *
Email Address: *
Cell Phone Number: *
Address (Including city, state, postal code, and country): *
Preferred Pronouns of Child: *
Sibling(s) name and date of birth (if more than one, please enter onto the next line):
Hospital Name in Boston: *
Doctor or Social Worker's Name:
Expected Arrival Date: *
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Expected Duration of Treatment: *
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