DO you know someone in need?

This REFERRAL FORM should be completed by someone at the organization making the referral, preferably someone who works most closely with the person in need. Once the form is submitted and we confirm eligibility for an award, you will receive a follow-up form asking for more details about the person and what they need.

If you have any questions, please send them to claire.fay@thegah.org.

Section A: Checklist for a Successful Referral

Below are the 10 key factors we consider in making awards. Please respond to each one.

1. This candidate is an adult (18+ years old).

Yes

2. I believe my candidate has great financial need and no medical insurance or personal resources to accomplish what is recommended for their situation.

Yes.

3. I am likely to see this candidate again six months to one year from now.

4. The product/service could be purchased for less than $1,000.

Section B: The Condition and Recommendation

In this section, please provide information about your candidate and their situation and the recommendation for addressing it.

1. Describe the health situation for which your candidate needs assistance.

2. Regarding the specific recommendation:

2a. Describe the recommended product/service.

3. Regarding the specific vendor/provider:

3a. Please list the specific product vendor or service provider.

4. Regarding the cost of the product/service my candidate needs.

Check all that apply.

The cost of the product/service is LESS than $1000.

The cost of the product/service is MORE than $1000.

The vendor/provider is offering a discount.

Funds have been identified to supplement the cost of the product/service (describe below).

4a. What other funds are available to supplement the cost of the product/service. (e.g., insurance, personal funds, other financial assistance, etc.)?

5. If needed to better understand your candidate’s need, are you able to assist in obtaining additional information from the candidate, within the constraints of honoring their confidentiality?

Section C: Contact Information

Your name.

First Name

Last Name

Your candidates name.

First Name

Last Name

Your email address.

Your phone number.

(###)

###

####

Your title or position.

Name of your organization.

Your organization's website.

http://

Any other comments or information you'd like to share.

Once you submit this form, you should hear back from us shortly, but in case you don't hear back within 2 or 3 days, please check in with a text to 202-437-4167.

Thank you.