Social Worker Form - Compassion Can't Wait

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*

Social Worker’s Full Name:

Email*

Phone*

Fax

Parent's Name:

Parent Phone

Single Parent:*

Yes

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

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

Other:

Please click the box below to fill in each specific request:

Enter Request

Request

Purpose

Due Date

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

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

Parent/Legal Guardian

Check to Sign

Full Name

Date

*If parent/guardian has Limited English Proficiency, please add interpreter’s signature attesting to interpretation in parent’s home language.

Phone

Number

Request

By Mail

By Social Worker

By Message