Healthcare Referral

Thank you for referring a family to Compass to Care.

After we receive your referral, a member of our team will contact the family directly to explain our program, gather the necessary information, determine eligibility and guide them through the next steps.

We look forward to the opportunity to help your patient and his/her family access care.

If you have questions about a referral or our transportation assistance programs, please contact Essy at Essy@CompassToCare.org. We greatly appreciate your partnership in helping children access the cancer care they need.

Child Referral for Compass to Care Support

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Child Information

Child First Name

Child Last Name

CHILD TRAVEL SCHEDULE: Please provide a detailed description of the child’s treatment plan that will necessitate travel for the family. THE INFORMATION PROVIDED BELOW WILL DETERMINE THE FUNDING LEVEL FOR YOUR PATIENT. SO PLEASE BE SURE IT IS AS ACCURATE AS POSSIBLE.

How Long is child's expected treatment?

How often will the child travel to the hospital over the next 3 months?

During the weeks he/she/they will travel, how many days will they travel?

OTHER DETAILS: Please include how often the family will travel, how many days and nights they will need to be at the medical center for each treatment, how many months, weeks, etc. the family will need to travel to complete the treatment. If you would like to share any additional information about this child, his/her family, their current financial situation, any additional support they are receiving, or any details that would be beneficial as we help them navigate travel to treatment, it will remain confidential.

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone

Medical Provider Details

Name of Child's Doctor

Name of Hospital Where Child is Receiving Treatment

Your Information

Your Name

Your Email Address

Your Phone Number

Your Title

By typing my name below, I understand that as a referrer to Compass to Care's program, I will be contacted at regular intervals (most often monthly) to provide updated travel details for this patient. This information will determine the patient's on-going eligibility. If I do not respond to the requests for information, the patient's support will be suspended until further details are collected from you or your team. In addition, I understand it is my responsibility to provide details to the Compass to Care Team if a child's treatment changes, the child stops receiving care, or the child passes away. This will help keep our records accurate and ensure we are providing the necessary support for travel needs.

Enter Your Name