Rainbow Kidz Events – Hospice & Palliative Care of Iredell County

Resources
Events
Referrals

Referrals

Thank you for your interest in the Rainbow Kidz program.
Please use the form below to connect with us and let us know more about your needs.

Once you complete this form, one of our counselors will be in touch with you
to discuss the services that we can provide.

Referrer Information

*Required Information

Name*

Relationship to Child(ren) Being Referred

Name of Organization
(if you are affiliated with a hospital, physician's office or other health care facility)

Phone*

Child(ren) Information

*Required Information

Name(s)*

Age(s)*

School(s) Attending*

Relation to Deceased

Date of Death

Type of Bereavement
Service Needed School Grief Support Group
Camp Rainbow
Individual Counseling Session

Parent/Legal Guardian Information

*Required Information

Name*

Family Contact Person

Address

Phone*

Who is the Best Person to Contact for a Follow-up?*

Other Details, Comments or Questions

Submit

Referrals

Referrer Information

Child(ren) Information

Parent/Legal Guardian Information

STATESVILLE OFFICE

MOORESVILLE OFFICE

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