SAILS Referral Form

SAILS Maryland Referral Form

This referral form is for individuals and families residing in Maryland who are seeking support from SAILS, or for professionals referring a Maryland resident.
Please provide the information below so our team can understand the family's immediate support needs and follow up appropriately. Additional information may be collected during intake.
Date of Referral:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who is providing this referral?
What is your relationship to the individual/family being referred?
Family Information

Please provide the information below for the individual or family member who will be receiving support from SAILS.
Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Format: (000) 000-0000.
How would you prefer to be contacted by SAILS?
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Race:
SAILS collects demographic information to help us better understand the families and communities we serve.
City:
County
Zip Code
State:
Loss Information
What type of loss was experienced?
Date of Loss
Baby's Name(s)
If you would like to share your baby's name(s) with us.
How far along was the pregnancy?
Example: 18 weeks, 22 weeks and 4 days
How old was the baby at the time of their passing?
Example: 2 days, 6 weeks, 8 months
What type of support is being requested?
Please describe the support being requested.
- Please tell us what type of resources or support you are looking for.
  This will help our team identify resources that may be helpful to you.
- Mailing Address for Keepsake Box
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Baby's sex
- Personal note
  If you are requesting a Keepsake Box for someone else, you may include a brief personal message for the family. SAILS will include your message with the box.
- Please answer the questions below so SAILS can better understand how we may support you with burial or cremation needs.
- Has a funeral home or cremation provider been selected?
- Would assistance locating a funeral home or cremation provider be helpful?
- Funeral home or cremation provider name
- Contact person's name, if known
  
  First NameLast Name
- Provider phone number
  Please enter a valid phone number.Format: (000) 000-0000.
- Provider email, if known
  example@example.com
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Upload available funeral home or cremation documentation
  
  Please upload a contract, estimate, invoice, or other available documentation from the selected provider.
  Cancelof
- Authorization to Contact Provider
- I authorize SAILS to contact the funeral home or cremation provider listed above to verify information related to this request for assistance.
- Please provide your information below so SAILS can contact you if clarification or additional information is needed regarding this referral.
- Referrer Name:
  
  First NameLast Name
- Organization, if applicable
- Referrer E-mail:
  example@example.com
- Referrer Phone Number:
  Format: (000) 000-0000.
- By typing the word "yes" in the box below, you confirm that you have spoken with the family/person in need regarding this referral.
- May SAILS contact you if we have questions or need additional information about this referral?
- Family Awareness & Consent
- How did you hear about SAILS?
- Please tell us how you heard about SAILS
  If you answered "Other", please explain.
- Would you like to receive informational and promotional material from SAILS?
- By submitting this referral, I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting a referral does not guarantee eligibility for or receipt of SAILS services or financial assistance. SAILS may contact the individual/family identified in this referral regarding available support and next steps.
- Signature of Person Completing This Referral
- Date signed
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearToday's date
Should be Empty:

SAILS Maryland Referral Form

Family Information

Loss Information

Authorization to Contact Provider