Family Application + Community Referrals
For community referral, scroll to the bottom of the application.
Better2gether is a 501(c)(3) nonprofit organization based in Richmond, VA, dedicated to supporting families of children with rare or complex medical conditions. The organization provides access to resources, information, and recreational programming. To be eligible for support, the child must have multiple significant chronic health issues and functional limitations, see five or more specialists, or be technology-dependent. Additionally, the child must reside in one of the following Virginia counties: Amelia, Charles City, Chesterfield, City of Richmond, Dinwiddie, Goochland, Hanover, Henrico, New Kent, Powhatan, or Prince George. Families living in Virginia counties outside our geographic service area can access the Family Resource Center directly through Children’s Hospital of Richmond (CHoR) if their child is a patient of CHoR. Our Family Navigator will reach out to you soon, but in the meantime, please visit our Resource page for a list of services, information, and financial support options. Please visit https://better2getherrva.org/resources for more information.
Child's Name
*
First
Last
Child's DOB
*
Month, Day
Year
Care Information
*
Child's Diagnosis(es)
Medical Provider
*
Primary Care Doctor
Location
Specialists
*
Endocrinology
Pulmonology
Hematology
Geneticists
Audiology/ENT
Urology
Cardiology
Gastroenterology
Oncology
Nephrology
Rheumatology
Sleep Medicine
Neurology
Immunology
Infectious Disease
Ophthalmology
Nutrition/Dietitian
Other
Does your child have a Medicaid Waiver? If so, which one?
CCC plus
FIS Waiver
CL Waiver
No, my chid does not have a Medicaid Waiver
If your child has a Medicaid Waiver, which MCO do you have?
Anthem
Aetna
Molina
Sentra
United Healthcare
HIPP-Straight Medicaid
My child does not have a Medicaid Waiver
Parent Information
*
Full Name
Address
Parent Information
*
Phone Number
Email
Preferred Method of Contact
*
Please Select
Phone
Email
Text
What support are you looking to gain from Better2gether?
How did you hear about us?
Participation Release: I understand that my participation and my child’s participation in the programs and activities of Better2gether RVA,(B2G) are entirely voluntary. For myself and my child I hereby release B2G, its officers, directors, agents and volunteers (“Representatives”) from any and all claims, injury, loss, damage or liability of every nature or kind whether seen or unforeseen, whether or not caused in whole or in part by the negligence or other misconduct of B2G or its Representatives in connection with any of the programs or activities of B2G.
Please Initial
Photo Release: I give permission to Better2gether RVA and its licensees and assigns (“Better2gether”) to photograph my children and me, and to publish, transmit and share in any form of media our names, photographs and any information that we have shared with Better2gether. I understand that our photographs and written materials may be edited and that the copyright belongs to Better2gether.*
Please Initial
Medical Information Release: I also authorize B2G on my behalf and on behalf of my child to contact agencies that B2G believes may be able to provide assistance or advice relating to my child’s condition. This authorization and request shall also be considered a consent to the release of such information under all applicable laws, rules, and regulations, to include but not be limited to the express grant of authority to personal representatives as provided by Regulation Section 164.502(g) of Title 45 of the Code of Federal Regulations and the medical information privacy law and regulations generally referred to as “HIPAA.” It is my intent that B2G be considered a personal representative under privacy regulations.
Please Initial
Community Referrals
We greatly appreciate the referrals from our community partners. If you are referring a family to Better2gether, please complete the following information:
Child's Name
Full Name
Child's DOB
Parent Information
Full Name
Email
Parent Information
Phone Number
Address
Preferred Method of Contact
Please Select
Phone
Email
Text
Does the family know they're being referred?
Please Select
Yes
No
Medically Complex Diagnosis
Reason for Referral
Name and Phone Number of Referring Provider
Any immediate needs we should be aware of
Disclosures
Submit
Should be Empty: