Refer a Child

Let the journey begin!

We care deeply about our kids. If you wonder if a FIGMENTATION® is right for your child, we recommend you speak to the child’s doctor about us before filling out the application

Child Referral Application

Relationship to the child

Has this referral been discussed with the child's healthcare provider

We recommend discussing this with the child's healthcare professional before referral.

Yes

CHILD'S INFORMATION

First Name

Last Name

Child's Birth Date

YYYY

Child's Age

Child has the cognitive ability of a fiver year old or higher

Yes

Child can communicate

Your child communication skills are at a level that enable them to articulate their unique story to our team.

Yes

Translator

If child needs a translator to effectively communicate with our team please specify.

Line

FAMILY INFORMATION

Parent/Guardian 1

First Name

Last Name

Relationship to child

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family's primary spoken language

Number of siblings

FAMILY CONTINUED

Parent/Guardian 2

First Name

Last Name

Relationship to child

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

MEDICAL INFORMATION

Primary Trauma

Please tell us why a little about your child's trauma

Date

Approximate Date of Trauma

YYYY

Is there any medical reason why we need to move quickly?

TREATING HEALTHCARE PROFESSIONAL INFORMATION

First Name

Last Name

Phone

(###)

###

####

Filling out this application doesn’t guarantee eligibility. After your information is reviewed you will be contacted by a member of our What-If team. You can also share our online inquiry form with someone who is qualified to refer a child.