Social Worker Referral Form

Patient’s Name / Social Worker's Name

Enter the Patient’s Name you are Referring.Social Worker’s Name
Social Worker's Email
example@example.com
Have you been issued a security pin code?
Pin Code
Job Title?
Hospital?
Social Worker's Email
Please enter your email.
Social Worker's Phone Number
Please enter your phone number.Format: (000) 000-0000.
Supervisor's Name

First NameLast Name
Supervisor's Phone Number
Please enter your supervisor's phone number.Format: (000) 000-0000.

What type of referral are you submitting? Please ensure that you select the same option in the following section.
Pager System: What assistance does the patient need? Please select the same option as above. This section helps identify the specific support required for your patient and pages us with Emergency cases 24/7.

Is the patient New or existing family of Meredith's Miracles?
What county does the patient live in?
Note: We only cover 26 counties
Patient's Name

First NameLast Name
Birth Date (We assist children birth-18 years old)

MonthDayYear
Parent's Name

First NameLast Name
Upcoming Appointments for this patient. If an appointment requires overnight stays please note that in the detail box below.
Medical Condition:
Example: Sickle Cell, Diabetes, form of cancer, etc.
Information about details on these trips you are referring. (Meredith's Miracles can provide lodging if appointments are before 9:00 am and/or if child has multiple appointments over consecutive days. Please tell us if you know they will be there multiple days.)
Note: Please give us as much details and opinions as possible to help us know what to fund.

Is the patient New or Existing family of Meredith's Miracles?
What county does the patient live in?
Note: We only cover 26 counties
Patient's Name

First NameLast Name
Birth Date (We assist children birth-18 years old)

MonthDayYear
Parent's Name

First NameLast Name
Upcoming Surgeries for this patient. Please include time of surgery so that we may indicate if overnight funding needs to be sent.

This must be deemed an emergency! Please Do Not pick this option unless it is a TRUE emergency. *Life flight, ambulance or emergency trip out of the child's area.
Is the patient New or existing family of Meredith's Miracles?
What county does the patient live in?
Note: We only cover 26 counties
Patient's Name

First NameLast Name
Birth Date (We assist children birth-18 years old)

MonthDayYear
Parent's Name

First NameLast Name
Parent's Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient is traveling to the following HOSPITAL & CITY for this emergency.
Transportation for Emergency:

Other
Emergency Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year Hospitalized (Release time TBD)
Please share any other details that you think might help us understand certain needs this family with this emergency:

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If the family you are doing the referral for has 4 or more scheduled appointments within a 30 day window you can select recurring treatments and submit all of the scheduled appointments. If the family you are doing the referral for has 3 or less scheduled appointments within a 30 day window, please select medical appointments and submit each date there.
Is the patient New or existing family of Meredith's Miracles?
Type of Cancer:
What county does the patient live in?
Note: We only cover 26 counties
Patient's Name

First NameLast Name
Birth Date (We assist children birth-18 years old)

MonthDayYear
Parent's Name

First NameLast Name
Scheduled Treatments: List each known Cancer Treatment for this month. Funding will be determined, based on the amount of trips taken per month.
Please share any other details that you think might help us understand certain needs this family with their cancer treatments:

Type of Assistance the patient received?
Patient's Name

First NameLast Name
Birth Date (We assist children birth-18 years old)

MonthDayYear
Confirmation baby is still admitted to NICU?
Parent visitation status?
Confirmation patient attended the following: Medical Appointment/Surgery/Recurring Cancer Treatment/ Hospitalization/EMERGENCY
Other details that will help us with this family:

This must be deemed an emergency! Please Do Not pick this option unless it is a TRUE emergency. *Life flight, ambulance or emergency trip out of the child's area.