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Refer a Child

To Refer a Child, fill out the online form below. Make sure to complete as much of the application as possible.

Today's Date
MM slash DD slash YYYY
Name of Child:
Date of Birth:
Parent(s) and/or Guardian(s):
Street Address:
City, State, Zip
Phone:
Phone:
Medical Diagnosis: (if any)
General Category of Request: (only check one)
- Medication or Medical Services
- Dental Treatment (must attach dental treatment plan)
- Medical Equipment
- Non-Medical Equipment (car seat, bed, mattress, etc.)
- Emergency Basic Needs (i.e. food, clothes, shoes, gas, etc.)
- Emergency Family Services (Must Impact Child's Health)
- Special Diet
- Glasses
- Therapy (speech, ot, pt, mental health, etc.)
- Adaptive Equipment or Conversions
- Other Health Needs
- Funeral/Cremation Assistance (invoice must be submitted with this request to be considered)
- Camping or Swim Scholarship
Specific Request:*
(specific item, therapy(s), & any other details needed to purchase, etc.)
Reason for Request:*
(family info including siblings/others living in home, family dynamics, employment & 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 )
List all other public or private resources that were exhausted prior to this request to Rest Haven.*
Supporting Documentation:
- Yes
- No
Attach File:
Max. file size: 50 MB.
Total Amount Requested:
(include tax & shipping, if applicable)
Services 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. If requesting grocery assistance, you MUST provide at least least 2 different preferred grocery stores.
Website:
Mailing Address:
Street Address
City, State, Zip
Contact Name:
Email:
Phone:
Referred By:
Name:
Title:
Agency:
Mailing Address:
Street Address City ZIP Code
Email:*
Phone:

Rest Haven in the Community

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April 11, 2023

Rest Haven is pleased to announce our 2023 Special Grants cycle is now open..... Read More

Rest Haven Makes Largest Single Donation in its History

September 29, 2022

Rest Haven is pleased to announce that it has awarded its largest grant ever.... Read More

Contact Us

Cass Kaminetz, Executive Director executive@resthavenchf.org

10531 4S Commons Drive, Suite 166-806
San Diego, CA 92127
858.576.0590

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