Rooms of Hope

Creating Spaces That Matter

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Referring A Child
Children’s Rooms
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Children’s Rooms and Referral Sources / Qualifications

– Step 1 of 3

Your Email *

Please enter your email, so we can follow up with you.

Q1. Does the child you are referring live in one of the nine bay area counties? {Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, or Sonoma} *

Yes
No

Q2. Is the child you are referring presently being treated for a life-threatening medical illness or condition? *

Yes
No

Q3. In six months, will this child be between the ages of 4 – 19 AND living at home with his/her parents/guardians? *

Yes
No

Q4. If you are not a family member, does one or both of the parents for this child know that you are referring this child to this program AND they are interested in being nominated to be part of our program? *

Yes
No

Q5. Is the child’s projected timeline of treatment, commonly referred to as “on treatment,” longer than six months? *

Yes
No

Q6. If selected, would the family be willing to provide us with a letter from the child’s medical doctor’s office stating that this child is presently being treated for a life-threatening medical illness or condition? *

Yes
No

Q7. Please include a paragraph or two as to why you feel the child would benefit from receiving a dream room makeover. (1,000 character limit with spaces) *

Congratulations!

The child you are referring qualifies for our program. As also mentioned on our website, we review child referrals four times per year as follows.

If your child qualifies for our program AND is accepted into our program, you can expect the following:

Rooms of Hope Referral Chart Timelines

When ready, please fill out the following questions:

Child's Full Name *

First

Last

Child's Nickname

Child's Primary Language Spoken at Home:

Child's Date of Birth *

Child's Age *

Child's Gender *

Female
Male

Child's Address *

Address Line 1

City

State

Zip Code

Primary/Secondary Medical Diagnosis

What is your child's primary/secondary medical illness or condition? *

Hospital? *

Medical Contact (Name, Address, Phone number, Email) *

(NOTE: If you don’t have this, we will ask the family)

Parent's / Guardian's Information? *

Parent's / Guardian's Best Contact Phone Number *

Parent's/Guardian's Primary Language Spoken at Home:

Parent's / Guardian's Address if different from the child's:

Do the Parents/Guardians rent or own their home/apartment where the child resides? *

Rent
Own
Other

Other, please describe

Siblings to the child (Please list names and ages of all those who live in the home):

Does each child have their own bedroom? If not, who shares a room together?

Referral Source and Contact Information: *

(Name, Title, Address and phone Number)

We’re sorry, but our program is only open to children who reside in one of the nine bay area counties.

We’re sorry, but our program is only open to children between the ages of 4 thru 19 AND reside with their parent or guardian.

We’re sorry, but our program is only open to children that are battling a life-threatening illnesses or conditions.

Please connect with the family to see if our program is a good fit. If so, visit our website again to refer this child.

We’re sorry, but our program is designed so that children who are “on treatment” receive a dream room makeover. Those children “on maintenance” do not qualify.

We’re sorry, but our program requires a medical doctor’s/office letter as part of qualifying each child for our program.

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