Hospital Referral for Love Bus Programming

Hospital Referral for Love Bus Programming

Refer a childhood cancer family to Love Bus for integrative therapy support.
Thank you for referring a family to Love Bus! Our individual funding for integrative therapies is available for childhood cancer patients in New England. Please fill out the information below as able and allowed, and we will be in touch with you or the family directly to discuss the availability of our funding and next steps.

The BEST way to help the family is to direct them to our application at lovebus.org/application (fastest way to get them connected to therapies).

Questions? Contact Kerry at kerry@lovebus.org or 781-454-8535.

This is the referral application for integrative therapy support (paying for massage, acupuncture, dance, swim, therapeutic horseback riding, etc). We do not offer direct financial assistance; for that support, please see our Resources page.
Family Referral
Your name
Your job title/connection to family
Hospital/organization
Your email
example@example.com
Your phone number
By clicking here, I certify that any information provided about the family is shared with their permission.
Patient Information
Patient’s Name
Patient’s Date of Birth

MonthDayYear
Date
If the patient is over the age of 18, please advise if we should contact them directly, or contact the guardian.
Who should we contact?
Patient’s diagnosis
City/town of residence
State of residence
Contact Person
Name of person to contact
Relationship to patient
Contact’s email
example@example.com
Contact’s phone number
Contact’s preferred method of contact?
Contact’s preferred language
Other language (please specify)
Therapy Preferences
Patient’s chosen therapies?

Other
Service location needs
Additional Information
Additional comments/notes?
Medical Permission
We must secure a medical permission form signed by the child’s oncologist clearing his/her participation in the therapy of his/her choice. The permission form can be sent separately from the complete application, but must be received before the child begins services.

Click here to download the medical permission form to help the family secure the necessary signature.
If you have a signed medical permission form for this patient, please upload here.

Cancelof
This referral form is so that we can get in touch with a family, tell them more about our programs, and have them complete a full application. The family will still need to complete the full application before moving forward.
Should be Empty:

Hospital Referral for Love Bus Programming

Family Referral

Patient Information

Contact Person

Therapy Preferences

Additional Information

Medical Permission