Refer a Child | Rest Haven Children's Health Fund

Hidden
Rest Haven Admin Use Only
Hidden
Final Status
Hidden
Record
Hidden
Email/Letter Status
Hidden
Date Correspondence Sent
MM slash DD slash YYYY
Hidden
Outstanding Tasks
Hidden
Payment Method
Hidden
Description of Gift
This form has been updated. Please fill in all required fields and be as specific as possible.
Today's Date*
MM slash DD slash YYYY
Child's Information
One child per referral form.
Child's Name*
First Last
Child's Date of Birth:*
County of Child's Permanent Residence*
Rest Haven provides funding only to children ages 0-17 who permanently reside in San Diego County or Imperial County in the State of California. Please indicate in which county the child currently resides.
Parent(s) or Guardian(s) Information
First Parent or Guardian*
First Last
Second Parent or Guardian
First Last
Parent/Guardian Address*
Street Address Address Line 2 City State ZIP / Postal Code
Parent/Guardian Cell Phone:*
Parent/Guardian Alternate Phone:
Parent or Guardian Primary Email Address (required)*
All correspondence we send to the parent/guardian regarding donations for the child will be sent to this email address. Do not use social worker's or referring agency email. FAILURE TO PROVIDE AN EMAIL ADDRESS FOR PARENT/GUARDIAN WILL RESULT IN AUTOMATIC DENIAL.
Parent or Guardian Secondary Email Address (if any)
Child's Health Information and Reason for Request
Please be as specific as possible to avoid delays.
Medical Diagnosis:*
General Category of Request*
All requests must impact the child's health.
- Adaptive Equipment or Conversions
- Camping or Swim Scholarship
- Dental Treatment (must attach dental treatment plan)
- Emergency Basic Needs (specific items such as food, clothes, shoes, diapers)
- Emergency Family Services (gift cards)
- Funeral/Cremation Assistance (invoice must be submitted with this request to be considered)
- Glasses
- Medical Equipment
- Medication or Medical Services
- Non-Medical Equipment (car seat, bed, mattress, etc.)
- Special Diet
- Therapy (Speech, OT, PT, Mental Health, etc.)
- Other health needs not described above
Specific Request:*
Describe the item, therapy, equipment, treatment, etc., and any other details needed for us to make a determination as to this request.
Reason for Request:*
Provide details regarding the family's circumstances, including siblings/others living in home, family dynamics, employment and financial status, extenuating circumstances that lends support to request, other funding resources pursued, how request will impact child’s health and any other pertinent information to help in determination. If the child/family is NOT currently enrolled in Medi-Cal, please provide a gross estimate of 2023 income and expenses below.
List all other public or private resources that were exhausted prior to this request to Rest Haven.*
Rest Haven’s mission is to provide funds for health related services for children in San Diego and Imperial counties when no other funds are available. You must describe other resources you have pursued in order to be considered.
Total Amount Requested:*
(include tax & shipping, if applicable)
Supporting Documentation
Upload any supporting documentation (if any), such as an invoice, medical documentation, etc. here.
Max. file size: 50 MB.
Services Receiving
Tell us what services the patient and/or their family is currently receiving.
(only check those that apply)
Medi-Cal
- Medi-Cal
Type of Coverage:
Denti Cal
- Denti-Cal
Type of Coverage:
Private Medical Insurance
- Private Medical Insurance
Type of Coverage:
Private Dental Insurance
- Private Dental Insurance
Type of Coverage:
Other Health Coverage
- Other Health Coverage
Type of Coverage:
California Children’s Services
- California Children’s Services
Type of Coverage:
San Diego Regional Center
- San Diego Regional Center
Type of Coverage:
In Home Supportive Services
- In Home Supportive Services
Type of Coverage:
Vendor Information
Vendor:*
Note where item/service can be purchased.
Website
Vendor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vendor's Contact Name:
Vendor's Email Address:
Vendor's Phone:
Information About Person Making the Referral
Unfortunately we cannot accept self referrals. All Emergency Referral Grants must be made by a social worker, case worker, school administrator or counselor, or someone with similar professional credentials.
Person Making Referral*
First Last
Title:*
Full Name of Agency, Hospital, Nonprofit, School, etc.*
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Referring Person's Email Address:*
Phone:*
Additional Information (optional)

Rest Haven Admin Use Only

This form has been updated. Please fill in all required fields and be as specific as possible.

Child's Information

Parent(s) or Guardian(s) Information

Child's Health Information and Reason for Request

Services Receiving

Vendor Information

Information About Person Making the Referral

Rest Haven in the Community

Rest Haven Announces 2023 Special Grants Recipients

Rest Haven Receives $2,100 in Donations

Contact Us