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?*

YesNo
Pin Code*
Job Title?*
Hospital?*
Social Worker's Email*
Please enter your email.
Social Worker's Phone Number*
Please enter your phone number.
Supervisor's Name*

First NameLast Name
Supervisor's Phone Number*
Please enter your supervisor's phone number.

Are you submitting an Upcoming Visit or Confirming a patient attended a visit?*

UpcomingConfirmation

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.

NICU (or PICU, RNICU, CVICU)Medical AppointmentSurgeryHospitalizationRecurring Cancer Treatment (Select if 4 or more appointments are scheduled per month if not select "Doctor Appointment")EMERGENCY!!!!! (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 your area.)

Is the patient New or existing family of Meredith's Miracles?*

NewExistingUnknown if they have ever been helped by Meredith's Miracles.
What county does the patient live in?*
Note: We only cover 27 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?*

NewExistingUnknown if they have ever been helped by Meredith's Miracles.
What county does the patient live in?*
Note: We only cover 27 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.

Is the patient New or Existing family of Meredith's Miracles?*

NewExistingUnknown if they have ever been helped by Meredith's Miracles.
What county does the patient live in?*
Note: We only cover 27 counties
Patient's Name*

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

MonthDayYear
Parent's Name

First NameLast Name
Hospitalization Dates

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?*

NewExistingUnknown if they have ever been helped by Meredith's Miracles.
What county does the patient live in?*
Note: We only cover 27 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.
Patient is traveling to the following HOSPITAL & CITY for this emergency.
Transportation for Emergency:

AmbulanceLife FlightPersonal CarOther
Emergency Date

MonthDayYear
Hospitalized (Release time TBD)
Please share any other details that you think might help us understand certain needs this family with this emergency:

Is the patient New or existing family of Meredith's Miracles?*

NewExistingUnknown if they have ever been helped by Meredith's Miracles.
Type of Cancer:*
What county does the patient live in?*
Note: We only cover 27 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?

YesNo
Parent visitation status?*

Yes, at least one parent is at bedside or visiting 4 or more times a month.No parent is visiting *Funding will not be approved if at least one parent is not at bedside or visiting 4 or more times a month.
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.