Refer A Family - UIC Division of Specialized Care for Children

Caregiver's Name*

Who should we contact?

Child's Name*

What is the child's name?

Child's Date of Birth

Caregiver's Phone Number*

What phone number should we use to contact the family?

Caregiver's Email Address*

What email address should we use to contact the family?

Caregiver's Street Address*

If we can't reach the family by phone/email, we will mail them general information about our program.

City*

State*

Please note we can only serve Illinois residents.

Zip Code*

The family's zip code tells us which regional office will help them.

County

The family's county tells us which regional office will help them.

Family's Primary Language

What is the family's preferred language?

Child's Diagnosis

Please describe the child's medical condition.

Has the child previously been enrolled with the Division of Specialized Care for Children?*

Yes
No
Do not know

What services does this family need?

PLEASE NOTE that financial support may be available for services and supports if they are included in the treatment plan for an eligible medical condition. All requests for financial assistance are subject to review and approval to ensure they meet program guidelines. We do not provide funding for all needs, and assistance is limited.

Care coordination
Financial assistance
In-home nursing
Finding resources
Diagnostic testing
Respite
Other

What type of insurance does the family have?

Public
Private
No insurance
Do not know

Are you referring yourself?*

Yes
No

Your Name*

Your Phone Number*

Your Email Address*

Is the family aware of this referral?*

Yes
No

Please share any other details that would be helpful for our team to know:

This gives us a little understanding before we contact them.

Email

This field is for validation purposes and should be left unchanged.