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Request a Room Form

You can request a room at the RMHC Richmond online. A staff member at RMHC Richmond will contact you to complete your request. Please call 804-355-6517 if you have not heard from a staff member within 2 hours of completing this request.

"*" indicates required fields

Stay Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Duration of Stay*

Patient Information

Patient Name*
Must be 21 or Younger

Primary Guest Information

Other Guests

First Guest Name
Age of first guest
Relationship of first guest to patient
Second Guest Name
Age of second guest
Relationship of second guest to patient
Third Guest Name
Age of third guest
Relationship of third guest to patient

Special Needs?

Does the family need transportation?*
Do any guests have any physical limitations that would prevent them from climbing stairs?*
This field is for validation purposes and should be left unchanged.