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Thank you very much for your interest in the NICH program!
Please provide your information including name, title, and specialty:
What is your email address where you can receive secure messages regarding this referral?
MRN of patient you are referring to NICH:
Patient's primary medical diagnosis (check ONE):
Type 1 diabetes
Type 2 diabetes
Chronic liver disease
Liver transplant
End stage renal disease on dialysis
Kidney transplant
Intestinal failure
Intestinal transplant
IBD
Complex congenital heart disease
Heart transplant
Neurodevelopmental disabilities
CF
Other (please specify)
Patient's other diagnoses (check ALL that apply):
Type 1 diabetes
Type 2 diabetes
Chronic liver disease
Liver transplant
End stage renal disease on dialysis
Kidney transplant
Intestinal failure
Intestinal transplant
IBD
Complex congenital heart disease
Heart transplant
Neurodevelopmental disabilities
CF
Seizures
Asthma
Mental health concerns (eg anxiety, depression)
Behavior concerns
Autism spectrum disorder
Other (please specify)
Teams involved in patient's care (check ALL that apply)
Endocrinology
Gastroenterology
Liver/intestinal transplant
Nephrology
Kidney transplant
Cardiology
Heart transplant
Pulmonary
Neurology
Surgery
Pain team
Complex primary care
Psychology/ psychiatry
SAFTeam
Palliative care
PT/OT
Home nursing or public health nurse
CORE
Other (please specify)
Psychosocial challenges for this patient and family (check ALL that apply)
Limited financial resources
Language barriers
Limited overall literacy / numeracy
Limited health literacy
Transportation
Housing instability
Patient mental health issues
Family mental health issues
Prior or current CPS involvement
Patient or family substance use
Limited supports (eg single parent household)
Lack of trust in health system
Poor communication with healthcare team
Absence of strong therapeutic relationship with team
Patient behavioral issues
Patient or family victims of violence
Caregiver unemployment
Food insecurity
Medical trauma
Other (please specify)
Patient and family's primary language
English
Spanish
Other (please specify)
Please write a few sentences to describe why you would like to refer this patient to the NICH program.
What are you hoping could be accomplished with NICH participation? (Check ALL that apply)
Improved health outcomes
Improved patient/ family quality of life
Reduced hospitalizations
Reduced ED visits
Improved ability to discharge from the hospital
Improved communication between care team and family
Improved relationship/ trust between family and healthcare team
Improved patient/ family experiences
Reduced stress on the health care team
Improved access to health technology
Readiness for needed intervention, such as surgery or transplant (specify)
Other (please specify)
How did you hear of NICH?
From a member of the NICH team (Diana Naranjo, Emily Ach, Rachel Bensen, Ale, Bruna, Jessica, Melissa)
Prior experience working with the program
SW
Other (please specify)
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