CBTF Family Referral Form
The Children's Brain Tumor Foundation is committed to supporting families impacted by a brain or spinal cord diagnosis throughout their journey. The information you provide here will allow us to connect you or your family member with someone who can help. Upon completing this form, a CBTF staff member will reach out and set up a time to talk.

Please provide as much information as possible, including the preferred mode of communication. Participation in programs offered by CBTF are voluntary and CBTF will not share the information you provide.

Thank you for reaching out. If you have any questions, please contact Regina Karchner at rkarchner@cbtf.org.

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Your first name *
Your last name *
I am (describe your role in relationship to the brain tumor patient) *
Best contact phone for you *
Best contact email for you *
Street Address *
City *
State *
Child's (patient) name *
Child's age *
Child's diagnosis *
Treatment hospital *
Child is *
Please share any additional information about the child's current medical condition. 
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 your family is seeking (check all that apply).
Is there anything else you would like to share?
Submit
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