SAILS Referral Form

SAILS Referral Form

This form shall be completed for Out-of-State/Country referrals ONLY.
Date of Referral:*

MonthDayYear
Date
Who is providing this referral?
Please explain:
If you answered "other" to Who is providing this referral, please explain.
Individual Needing/Requesting Assistance:

In the section below answer the questions for the invidual who is needing services.
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Birth Date:*

MonthDayYear
Date
Race:*
Please explain:
If you answered "other", please explain.
Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
What type of assistance is needed?:

Grief Support (8 week in-person or virtual group)Keepsake Box (purple magnetic box to store precious items; MD residents ONLY)Loss Moms Open Hour (monthly online support group)Pilot (Grief Support for ages 18 to 24 y/o)
What type of assistance is needed?: {out of country}

Grief Support (8 week in-person or virtual group)Loss Moms Open Hour (monthly online support group)Pilot (Grief Support for ages 18 to 24 y/o)
What type of loss was experienced?*
Please explain:
If you answered "other", please explain.

Referrer's Information
In the section below answer the questions for the individual who is providing this referral.
Name of Referring Organization:*
Name:*

First NameLast Name
E-mail:
example@example.com
Phone Number:
By typing the word "yes" in the box below, you confirm that you have spoken with the family/person in need regarding this referral.

Other Information
How did you first hear about us?
Please explain:
If you answered "other" please explain.
Can we follow up regarding the outcome of this referral?

YesNo
Would you like to receive informational and promotional material from SAILS?

YesNo