Provider Reference Form (Margaret Freedman)

Dear Provider,

The following family has requested that you fill out the following reference form as part of their Preston Ranch Ministries grant application. The form must be completed before the family’s application can be reviewed. Thank you in advance for your timely response. We look forward to learning more about the family!

Parent/Legal Guardian Name

First Last

Parent/Legal Guardian Phone

Parent/Legal Guardian Email

Child's Name

First Last

Child’s Date of Birth

Provider Information (please make changes as necessary)

Provider Name

First Last

Provider Credentials(Required)

Provider Email

Provider Phone

How long have you been treating the patient?(Required)

What medical conditions are you currently treating the patient for (including any chronic or significant health issues the patient is facing)?(Required)

Are there any additional services, therapies, or interventions you would recommend for the patient?(Required)

How well does the patient follow medical advice and treatment plans? Does the patient consistently attend appointments and follow up on medical care?(Required)

How does the patient’s medical condition impact their daily functioning or quality of life and are there any limitations or special needs the patient has because of their condition?(Required)

How would you assess the patient’s overall health and progress in managing their condition(s)? Are there any concerns regarding the patient’s ability to manage their health independently or with family support?(Required)

What is the patient’s prognosis based on their current treatment plan? Are there any long-term health concerns that may require ongoing or extended care?(Required)

Do you offer a sliding-scale or income-based fee structure, and has this family requested it?(Required)

Would you recommend this family for the Preston Ranch Ministries Medical Grant? Why or why not?(Required)

Is there anything else you feel we should know about the patient’s medical situation or care requirements?(Required)

Type in your name that you acknowledge all the information provided is true and accurate to the best of your knowledge.

I agree(Required)