Healthcare Provider Family Support Referral Form
For Social Workers and other healthcare and service providers for a family temporarily relocated to Seattle for treatment of serious illness. Family should be in Seattle for at least two more months and reside near Seattle Children's Hospital or Fred Hutch, have one or more children needing weekly play and friendship, and be appropriate to match to non-professional volunteers (no history of violence or current substance abuse).
Referral Source Information
Today's date:
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Your name, first and last
Your answer
Your relationship to the family
Your answer
Your email
Your answer
Your phone
Your answer
Is the family aware of your referral?
Family Information
Caregiver #1 full name and relationship to patient
Your answer
Caregiver #2 name and relationship to patient
Your answer
Caregiver #3 name and relationship to patient
Your answer
Caregiver #1's Marital Status
Your answer
Primary Language spoken by Caregiver(s)
History of drug/alcohol abuse?
History of violence?
Patient's full name
Your answer
Patient's age and gender
Your answer
Diagnosis
Your answer
Date of diagnosis
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Estimated length of support (example: 4 months)
Your answer
Names, ages, and genders of siblings with family in Seattle
Your answer
Family Contact Information
Seattle Residence (RMH, Pete Gross House, apartment or house rental, etc.)
Your answer
Caregiver #1's cell phone number and email
Your answer
Family's previous residence (city, state)
Your answer
Description of Volunteer Support Requested
Family Needs
Anything else we should know about the family?
Your answer
Specific type of volunteers requested (age, gender, personality, experience):
Your answer
All information submitted is solely for the use of Side-by-Side and will be kept confidential. Thanks for your referral!
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