A Room to Heal Referral Form
Please complete this form to refer a child for a Healing Room Project or Comfort & Care Kit.
Submission of a referral does not guarantee that the project will be approved. Priority is given to children with the most serious conditions. 
If you would like to refer an organization, please email us at aroomtoheal@gmail.com.
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Child's Name (First and Last) *
Child's Birthday  *
MM
/
DD
/
YYYY
Medical Diagnosis *
Parent's/Caregiver's Name(s) *
Street Address
City
State
Zip Code
Parent's/Caregiver's Home Phone
Parent's/Caregiver's Cell Phone
Parent's/Caregiver's Email Address
 *
Your Name *
Your Phone
Your Email
Relationship to Child
Please describe how a Healing Room Project or Comfort & Care Kit would benefit this child *
Please tell us how you heard about us (i.e. another room family, doctor, school, etc.)
I acknowledge that the information in this referral will be reviewed by A Room to Heal staff, Board of Directors, and project committee for evaluation and planning. I confirm that I have permission from the parent or legal guardian to share these details.   *
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