Referral Form
This form is for medical professionals only. If you would like to make a self referral, please use our contact form or call us at 513-731-3346 and ask for Intake.
Date
-
Month
-
Day
Year
Date
Demographic Information
Name of person referred
*
First Name
Last Name
Email of person referred
*
Mailing List
No
Patient Contact Type
Referred/Received Services
Created by Jotform
Created by Jotform
Gender
*
Male
Female
Other
Please list other gender
*
D.O.B
*
-
Month
-
Day
Year
Date
Zip Code of person referred
*
Best Phone # to reach person referred
*
Format: (000) 000-0000.
Cancer Information
Cancer Patient
Please Select
Yes
No
Cancer Patient Yes?
Yes
Non-Patient Yes?
Yes
Cancer Patient
Yes
No
Cancer Type
*
Bone
Brain
Breast
Colo-Rectal
Head and Neck/ENT
Gynecological (Non-Ovarian)
Kidney
Leukemia
Lung
Lymphoma
Melanoma
Multiple Myeloma
Ovarian
Pancreatic
Prostate
Stomach
Other
Please list other cancer type
*
Disease Status at the Time of Referral
*
Newly Diagnosed
In Treatment
Remission/Survivorship
Relapse
Palliative Care/Hospice
Bereavement
Current Disease Status
Newly Diagnosed
In Treatment
Remission/Survivorship
Relapse
Palliative Care/Hospice
Bereavement
Physician Name
*
Physician First Name
Physician Last Name
Physician
CFC Services:
Individual and Family Counseling
- provides mental health counseling through private, personalized individual, couples, and family sessions (in person and telehealth)
Treehouse Children's Counseling
- provides mental health counseling to youth ages 5 -18 with a loved one battling cancer; school groups and Camp Courage are also available
Coping Connection
- provides information on CFC services and other cancer related organizations.
Free Wig Program
- provides free wigs, hats, scarves and other items to cancer patients.
Financial Assistance
- provides very limited, one-time assistance to breast cancer patients in Ohio through a grant from the Breast Cancer Fund of Ohio.
Waddell Family Healing Hands
- Provides oncology massage and Healing Touch to cancer patients currently in active treatment (Radiation and/or Chemotherapy)
Services Needed
*
Individual and Family Counseling
Treehouse Counseling
Coping Connection
Free Wig Program
Financial Assistance
Waddell Family Healing Hands
Reason for Referral
*
Referred By (Your Contact Information):
Referral Name
*
First Name
Last Name
Referral Email
*
example@example.com
Referral Phone Number
*
Format: (000) 000-0000.
Referral Contact Type
Medical Professional
Referral Specialty
*
Physician
Nurse
Social Worker
Other
Please list other Referral specialty
*
Medical System
*
Children's
Christ
Mercy
OHC
St. Elizabeth
TriHealth
UC
Kettering
Premier
Wright Patt
The James/OSU
Other
Please list other Medical System
*
Hospital or Office Location
*
Mercy Anderson
Mercy Eastgate
Mercy Fairfield
Mercy Jewish Hospital
Mercy Kenwood
Mercy West
OHC - Blue Ash
OHC Clifton
OHC - Eastgate
OHC Fairfield
OHC-Kenwood
OHC-West
St. Elizabeth Cancer Center- Dearborn
St. Elizabeth Cancer Center - Edgewood
St. Elizabeth Cancer Center - Florence
St. Elizabeth Cancer Center-Ft. Thomas
St. Elizabeth Cancer Center-Grant
The Christ Hospital Cancer Center - Anderson
The Christ Hospital Cancer Center - Ft. Wright
The Christ Hospital Cancer Center - Green Township
The Christ Hospital Cancer Center - Mason
The Christ Hospital Cancer Center - Montgomery
The Christ Hospital Cancer Center – Mt. Auburn
The Christ Hospital - Palliative Care
The Christ Hospital Cancer Center - Red Bank
TriHealth (Bethesda) Thomas Center
TriHealth (Good Samaritan) - Clifton
TriHealth -Anderson
TriHealth - Arrow Springs
TriHealth - Bethesda Butler
TriHealth - Kenwood
TriHealth - Oxford
TriHealth - Western Ridge
UC Barrett Cancer Center
UC Proton Therapy Center
UC West Chester Hospital
UC - Brain Tumor Center
Person referred gives permission for communication with medical system care team.
*
Yes
No
Person referred is aware that this referral is being made.
*
Yes
No
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