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Refer a Child

To Refer a Child, fill out the online form below,
or Download the form & email to resthavenchfund@sbcglobal.net or fax to 858-576-0029.

Individual Referral Form - Rest Haven Children's Health Fund

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, etc.)
- Emergency Family Srvcs (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
- Camping 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 )
Supporting Documentation:
- yes
- no
Attach File:
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:
(where item/service can be purchased, website, etc.)
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:

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Contact Us

Phone: 858.576.0590

Fax: 858.576.0029

Email: resthavenchfund@sbcglobal.net

© Copyright 2016 Rest Haven Children’s Fund

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