Healthcare Referral Form

Healthcare Professional Referral Form

Kairi's Star Foundation works with healthcare professionals to help identify families facing financial, geographic, or logistical barriers to accessing specialized medical care. Please complete this referral form with the information available to you. Submission of a referral does not guarantee assistance; all requests are reviewed based on eligibility, verification, available funding and current program capacity.

Referring Professional First Name

Referring Professional Last Name

Referring Professional Email

Referring Professional Phone Number

Hospital/Healthcare Organization

Referring Professional Title/Role

Child/Patient First Name

Child/Patient Last Name

Child/Patient Date of Birth

Child/Patient Diagnosis

Child/Patient Date of Diagnosis

Treatment Medical Facility/Medical Team

Reason the Professional is Referring the Family/What Assistance is Needed

How Urgent/Time-Sensitive is This Referral?

Immediate-Assistance Needed Within 24-48 Hours

Urgent-Assistance Needed Within 3-7 Days

Time-Sensitive-Assistance Needed Within 1-2 Weeks

Standard-Assistance Needed Within More Than 2 Weeks

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone Number

Has the Parent/Guardian Given Permission for Kairi's Star Foundation to Contact Them?

Yes

Family is Traveling From

Family Needs to Travel To

Receiving Medical Facility

Expected Travel or Appointment Date

Has the Medical Facility Confirmed the Appointment or Evaluation?

Yes

Brief Explanation

Are There Siblings or Other Necessary Family Members Whose Circumstances Could Prevent This Family from Reaching Care or Remaining Together?

Yes

If Yes, Please Explain

Number of Parent/Guardian Travelers

Number of Sibling Travelers

Number of Other Necessary Caregivers Travelers

Total Number of Travelers

Destination Country

Does the Child Currently Have a Valid Passport?

Yes

Unknown

Do Necessary Accompanying Family Members Have Valid Passports?

Yes

Unknown

Is Passport Assistance Needed?

Yes

Unknown

Can the Medical Need or Care Opportunity be Verified Through the Referring Professional or Medical Facility?

Yes

Unknown

Is Another Organization, Hospital Program, or Other Resource Already Helping?

Yes

Unknown

If Yes, Please Explain What Assistance is Being Provided

Please Indicate What You Can Reasonably Verify

Child is currently under the care of or known to our institution/program.

Diagnosis has been medically confirmed.

The family is pursuing legitimate medical care or evaluation.

The destination facility or care opportunity is legitimate and appropriate.

The family is experiencing a barrier that may prevent or delay access to care.

Referring Professional Signature

Date

I Certify That the Information Provided in this Referral is Accurate to the Best of My Knowledge