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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:

Rest Haven in the Community

Announcement – Office to be Closed September 25 until November 5

September 24, 2018

Rest Haven Children’s Health Fund will be temporarily closing its office beginning September 25.... Read More

Thank You Medtronic!

September 24, 2018

Rest Haven Children’s Health Fund would like to acknowledge and thank the Medtronic Foundation.... Read More

Agencies- Sign Up to Receive Grant Notifications

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Agency Contact & Title*
Email*

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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