MENU

Refer a Child

Lurie’s Children’s Hospital patients who qualify for a Kiss of HOPE® will be automatically referred to our program by a Lurie’s Brain Tumor program social worker.  However, if your child meets the following requirements and is seen at another hospital, please fill out the form below.

  • Aged 0-18 years old
  • Resident of Illinois
  • Located in Chicagoland and surrounding counties
  • Diagnosed and in active treatment for one of the below brain/spine tumors

 

First
Last
Diagnosis will be confirmed by the patient’s attending physician. Please provide the following: