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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, 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 )
List all other public or private resources that were exhausted prior to this request from RHCHF:*
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:

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