The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

iBYJbAMvSfJrfGxmgJragsnMZkac3ULzk23zFjKfzy8iaBnTnLcnzPY9NHh9dxGRQpSLkbiydTAsgE5uRAAt

Family Resilience Fund Referral Form

Eligibility for this fund: Families with children age 0-26 living in the household where a primary caregiver (eg. parent/legal guardian/foster parent) is deceased due to Covid or a Covid related illness resulting in financial hardship for the family. Families must be referred by a treating clinician. Please note that completion of this referral does not ensure the applicant’s eligibility and that further assessment by a program staff member is required prior to acceptance.

Name of deceased breadwinner/caregiver

MR#

Age of Deceased

Last hospitalized at

Place of death

Home

Hospital

Other

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Place of death

Type of Burial

Burial

Cremation

Other

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Burial Type Other

Name of Household contact

Household Contact Preferred Language

Current legal guardian of minor children

Address

City

State

Zip Code

Phone

Work Phone

Cell Phone

Number of Adults in Household (above age 27)

Number of ADULTS (27 and above) in household:

Number of Children in Household (age 26 and under)

Number of CHILDREN (26 and under) in household

Child 1

Child 1 Name

Child 1 Age

Child 2

Child 2 Name

Child 2 Age

Child 3

Child 3 Name

Child 3 Age

Child 4

Child 4 Name

Child 4 Age

Child 5

Child 5 Name

Child 5 Age

Child 6

Child 6 Name

Child 6 Age

Number of adults contributing to household income

Source of income:

Public Assistance

SSI

SSD

SNAP

Unemployment

Other

Employment

Amount of Public Assistance

Amount of SSI

Amount of SSD

Amount of SNAP

Amount of Unemployment

Amount of other income

Amount of Employment Income

Approximate Household monthly income (average)

Insurance(s) (check all applicable)

Medicaid

Medicare

CHIP

Commercial

Do you have stable housing now?

Yes

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Are you concerned about losing your housing in the next 6 months?

Yes

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Are you concerned about paying utilities in the next 3 months?

Yes

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Are you concerned about paying for food in the next 3 months?

Yes

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Are you concerned about paying medical expenses (copayments) in the next 3 months?

Yes

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Additional Information:

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Name of Referrer

Phone

Work Email

License or Professional Role

* must provide value

Referrer Information (MD, DO, PA, PsyD, NP, RN, LMSW)

NYS License #

* must provide value

Referring Site

Date of Referral

M-D-Y

My signature confirms that this family is known to the organization where I am employed and has been contacted by me.

For questions, contact racevans@montefiore.org

* must provide value

Add signature

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