Family Intake & Referral Form

We know reaching out for help can feel overwhelming. This form helps us understand your situation so we can respond with care, fairness, and integrity. You do not need to have everything figured out. Share what you can today and a member of our team will follow up with you.

Request Understanding*

I understand this form does not guarantee assistance and that all requests are reviewed based on eligibility and available resources.

How are you connected to this request?

I am a parent or legal guardian requesting support for my family

I am referring a family

While the fields in this form are optional, providing as much information as you feel comfortable sharing helps Hand to Heart Village better understand your family’s situation and determine how we may best support you.

Referral Contact Info

First Name

Last Name

Relationship to Family

Relationship to Family (other)

Phone Number

Preferred method of contact

Referring Agency

Check if same as Hospital / Clinic Address

Work Address

City

State

Zip Code

Preferred Guardian Info

First Name (G1)

Last Name (G1)

Relationship to Patient(s)(G1)

Relationship to Patient(s) (other)

Phone Number

Preferred method of contact

Home Address

City

State

Zip Code

Add a guardian

Guardian #2 Info

First Name (G2)

Last Name (G2)

Relationship to Patient(s)(G2)

Relationship to Patient(s) (other)

Phone Number (G2)

Email (G2)

Preferred method of contact (G2)

Same address as preferred guardian.

Home Address (G2)

City (G2)

State (G2)

Zip Code (G2)

Add an additional guardian

Guardian #3 Info

First Name (G3)

Last Name (G3)

Relationship to Patient(s)(G3)

Relationship to Patient(s) (other)

Phone Number (G3)*

Email (G3) *

Preferred method of contact (G3)

Same address as preferred guardian.

Home Address (G3)

City (G3)

State (G3)

Zip Code (G2)

Hospital / Clinic Info

This information allows us better provide support based on the distance to and from the hospital and your home, and the local going rate.

Hospital / Clinic Name

Hospital / Clinic Address

City

State

Zip Code

Phone Number

Does the Family know you are referring them?

Yes

Can you share information about the current situation with Hand to Heart Village?

Yes

Brief Overview of the Family’s Situation

Even a short note can help. Tell us whatever feels appropriate about what the family is currently facing and how they might best be supported.

Referred Family Info

First Name (G1)

Last Name (G1)

Relationship to Patient(s)(G1)

Relationship to Patient(s) (other)

Phone Number

Preferred method of contact

Home Address

City

State

Zip Code

Add a guardian

Referred Guardian #2 Info

First Name (G2)

Last Name (G2)

Relationship to Patient(s)(G2)

Relationship to Patient(s) (other)

Phone Number (G2)

Email (G2)

Preferred method of contact (G2)

Same address as preferred guardian.

Home Address (G2)

City (G2)

State (G2)

Zip Code (G2)

Patients Info

Preferred Name

Date of Birth

Age

Diagnosis

This helps Hand to Heart Village better understand the types of medical journeys families are navigating and improve future support programs.

Additional Info

Please share anything else you would like us to know about this child.

Medical Journey & Travel Section

This section helps us better understand the child’s medical journey, travel requirements, and the impact treatment may be having on the family.

Travel Distance (miles)

Frequency of Appointments

Current admission status

Length of Stay

Upcoming procedures

Family Support Needs Section

Every family’s journey is different. Please select the areas where support may be most helpful at this time.

Other

Urgency

Additional Info

Please share anything else you would like us to know about this child.

Family Intake & Referral Form

Hand to Heart Village, INC is a registered South Carolina nonprofit and a federally recognized 501(c)(3) charitable organization dedicated to supporting families navigating pediatric medical crises.EIN: 39-2294389

Hand to Heart Village, INC is a registered South Carolina nonprofit and a federally recognized 501(c)(3) charitable organization dedicated to supporting families navigating pediatric medical crises.
EIN: 39-2294389