Patient Referral Form

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

MonthDayYear
Date
Demographic Information
Name of person referred*

First NameLast Name
Email of person referred*
Mailing List

No
Patient Contact Type

Referred/Received Services
Created by Jotform

Created by Jotform
Gender*

MaleFemaleOther
Please list other gender *
D.O.B*

MonthDayYear
Date
Zip Code of person referred*
Best Phone # to reach person referred*
Cancer Information
Cancer Patient
Cancer Patient Yes?

Yes
Non-Patient Yes?

Yes
Cancer Patient

YesNo
Cancer Type*

BoneBrainBreastColo-RectalHead and Neck/ENTGynecological (Non-Ovarian)KidneyLeukemiaLungLymphomaMelanomaMultiple MyelomaOvarianPancreaticProstateStomachOther
Please list other cancer type*
Disease Status at the Time of Referral *

Newly DiagnosedIn TreatmentRemission/SurvivorshipRelapsePalliative Care/HospiceBereavement
Current Disease Status

Newly DiagnosedIn TreatmentRemission/SurvivorshipRelapsePalliative Care/HospiceBereavement
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 CounselingTreehouse CounselingCoping ConnectionFree Wig ProgramFinancial AssistanceWaddell Family Healing Hands
Reason for Referral*
Referred By (Your Contact Information):
Referral Name*

First NameLast Name
Referral Email*
example@example.com
Referral Phone Number*
Referral Contact Type

Medical Professional
Referral Specialty*

PhysicianNurseSocial WorkerOther
Please list other Referral specialty*
Medical System*

Children'sChristMercyOHCSt. ElizabethTriHealthUCKetteringPremierWright PattThe James/OSUOther
Please list other Medical System*
Hospital or Office Location*

Mercy AndersonMercy EastgateMercy FairfieldMercy Jewish HospitalMercy KenwoodMercy WestOHC - Blue AshOHC CliftonOHC - EastgateOHC FairfieldOHC-KenwoodOHC-WestSt. Elizabeth Cancer Center- DearbornSt. Elizabeth Cancer Center - EdgewoodSt. Elizabeth Cancer Center - FlorenceSt. Elizabeth Cancer Center-Ft. ThomasSt. Elizabeth Cancer Center-GrantThe Christ Hospital Cancer Center - AndersonThe Christ Hospital Cancer Center - Ft. WrightThe Christ Hospital Cancer Center - Green TownshipThe Christ Hospital Cancer Center - MasonThe Christ Hospital Cancer Center - MontgomeryThe Christ Hospital Cancer Center – Mt. AuburnThe Christ Hospital - Palliative CareThe Christ Hospital Cancer Center - Red BankTriHealth (Bethesda) Thomas CenterTriHealth (Good Samaritan) - CliftonTriHealth -AndersonTriHealth - Arrow SpringsTriHealth - Bethesda ButlerTriHealth - KenwoodTriHealth - OxfordTriHealth - Western RidgeUC Barrett Cancer CenterUC Proton Therapy CenterUC West Chester HospitalUC - Brain Tumor Center
Person referred gives permission for communication with medical system care team.*

YesNo
Person referred is aware that this referral is being made.*

YesNo
Should be Empty:

Referral Form

Demographic Information

Cancer Information

Referred By (Your Contact Information):