CBTF Healthcare Professional Referral Form
Thank you for making a referral to the Children’s Brain Tumor Foundation (CBTF).  CBTF provides support for survivors and families affected by a brain or spinal cord tumor diagnosis. 

The information you provide below is helpful in facilitating contact and support for the family. Please provide as much information as possible, including the family's preferred mode of communication.

By completing this form, you acknowledge the family understands that the hospital is making a referral on the family’s behalf to the Children’s Brain Tumor Foundation, and therefore, their name, contact information, and basic medical information (diagnosis, age) will be shared with the Children’s Brain Tumor Foundation. Participation in programs offered by CBTF are voluntary and CBTF will not share the information you provide.

Thank you for connecting with us. If you have any questions, please contact Stephanie Freeman at sfreeman@cbtf.org. 

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Your name and position *
Referring hospital *
Best contact phone for you *
Best contact email for you *
Parent/caregiver name *
Parent/caregiver email *
Parent/caregiver phone *
Mailing street address  *
City *
State *
Zip  *
Child's (patient) name *
Child's date of birth *
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Child's age *
Child's gender *
Child's preferred pronouns
Child's diagnosis *
Date of diagnosis *
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Child is *
Please share any additional information about the child's current medical condition. 
Any siblings? Please list names and ages. If none put N/A. *
Child's Ethnicity *
Required
If other, please specify.
Preferred method of contact *
Are there any language or cultural barriers that would be helpful for us to know?
Please indicate the types of resources and support the referred family is seeking.
CBTF Care Kits
Newly diagnosed families are eligible to receive a CBTF Care Kit which includes resources, small gifts for the patient and siblings and letters of support. Care kits are sent each month. Families are contacted to confirm the information provided on this form before the kits are sent.
Would you like a Care Kit to be sent to the referred family? *
Required
Would you prefer information in Spanish if it is available?   *
Is there anything else you would like to share?
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