Social Worker Form - Compassion Can't Wait

Compassion Can't Wait

info@compassioncantwait.org
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Compassion Can’t Wait

For Single Parent Families of Children with Life Threatening Illnesses

We are pleased to assist your family by paying for urgent everyday needs during your child’s treatment and when all other resources are exhausted. Kindly have your child’s social worker fill out this form and click “Submit” to send the application electronically

Rev 07/2016
Hospital Name*
Date*
MM slash DD slash YYYY
Social Worker’s Full Name:
Email*
Phone*
Fax
Parent's Name:
Parent Phone
Single Parent:*
- Yes
- No
Child’s Name & Age:*
Home Address
Street Address City State ZIP Code
Siblings’ Ages and Gender:
Physician’s Name:
Diagnosis & Prognosis:
Description of Illness:
Currently Hospitalized:*
- Yes
- No
Description of family circumstances & members of household.
Housing:
- Owns
- Rents
- No current home
- Lives with others
Assistance Currently Received by the Family

Dear Social Worker, please tell us to what other agency you have reached out to for assistance. We are a small California foundation with a big mission—and an even bigger heart. But we know that each community has their specific support organization.
Note:- Therefore please turn to us as urgent, last resort organization, after having exhausted local resources.

We are aware that each hospital community has specific support organizations, therefore, please put a checkmark next to the resources for which you already applied:
Note:- Examples of local resources (they vary by hospitals and State).
Assistance
- American Brain Tumor Association
- American Cancer Society (ACS)
- Angel Flight
- AVONCares Program
- Candlelighters Childhood Cancer Foundation (CCCF)
- Care Resource Center (CRC)
- Child Care Resource List*
- Co-Pay Relief Program (CPR)
- Food Assistance Support*
- Food Stamp Program
- General Relief (GR)
- Health Insurance Assistance Service (HIAS/ACS)
- Homeless Shelters (various)*
- Hospice Assistance Program*
- Housing Assistance*
- In-Home Supportive Services (IHSS)
- Lance Armstrong Foundation
- Leukemia & Lymphoma Society
- Medi-Cal
- National Assoc. for the Terminally Ill
- National Children’s Cancer Society (NCCS)
- New Economics For Women (NEW)
- Oral Cancer Foundation
- Patient Access Network Foundation (PAN)
- Public Utilities Programs*: phone gas electric/water
- Religiously Affiliated Charities*
- Section 8 Housing (by area)
- Social Security Disability (SSD)
- Spencer Crawford Children’s Foundation, Inc
- Supplemental Security Income (SSI)
- Temporary Aid to Needy Families (TANF)
- Transportation/Travel Assistance*
- Other
Other:
Please click the box below to fill in each specific request:
- Enter Request
Request
Purpose
Due Date
MM slash DD slash YYYY
Payee
Amount Requested
Mailing Address
Street Address Address Line 2 City State ZIP Code
Phone
Account Number
Send to:
- Payee
- Social Worker
- Other
Request 2
Purpose
Due Date
MM slash DD slash YYYY
Payee
Amount Requested
Mailing Address
Street Address Address Line 2 City State ZIP Code
Phone
Account Number
Send to:
- Payee
- Social Worker
- Other
To help us expedite the assistance you need, when possible attach mortgage, invoices, other bills relevant to your request. Compassion Can't Wait, whenever possible will pay vendors directly.
Accepted file types: pdf, jpg, gif, png, Max. file size: 10 MB.
Or fax to (310) 276-0244
We ask permission to use your information in an effort to provide service and financial assistance for your family. This information may, with discretion, be shared on your behalf with service providers, utilities, landlords, etc. to aid and preserve your family’s financial welfare. We may also use information in order to promote the charitable goals of the Compassion Can’t Wait foundation. If you don’t wish to disclose information, this will not affect compassioncantwait.org’s willingness to assist your family.
By checking the box I agree that information I have entered above is completed and will be the electronic representation of my signature.
Social Worker*
- Check to Sign
Full Name
Date
MM slash DD slash YYYY
Parent/Legal Guardian
- Check to Sign
Full Name
Date
MM slash DD slash YYYY
*If parent/guardian has Limited English Proficiency, please add interpreter’s signature attesting to interpretation in parent’s home language.
Phone
Number

Δ

When compassion can't wait and single parent families are in despair, we help with urgent expenses to allow these caregivers to stay at their child's bedside during catastrophic illness.

We provide swift financial assistance in an unprecedented turnaround time.

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Compassion Can't Wait
P.O. Box 69A, West Hollywood, CA 90069

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(310)-276-7111

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