Wish Referral: Form for Healthcare Professional

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Make-A-Wish Canada can only review submissions from this form if it is submitted by an approved healthcare professional. Healthcare professionals may include a physician, nurse, nurse practitioner, social worker, child life specialist or another qualified member of the child’s medical who are actively part of the child’s healthcare team. Our Medical Advisory Committee and staff team will use information from this form to determine whether the child’s current medical condition meets the medical criteria to receive a wish.

Make-A-Wish Canada grants wishes to children who are between the ages of 3-17, who have not received a prior wish from any wish granting organization, who have a critical illness that is in a life-threatening stage (or with extreme long-term complications), who meet one or more of the following eligibility criteria:

Children whose current medical condition requires high-risk therapy to survive
Children who are dependent on technology to survive (e.g., tracheostomy; chronic assisted ventilation; transfusion-dependence)
Children who have chronic conditions that demonstrate extreme long-term complications
Children who are at high risk of sudden death

Please ensure you have read our wish eligibility criteria before submitting a referral. If you have any questions about the wish referral process, please contact us at referachild@makeawish.ca or 1.888.822.9474.

Make-A-Wish Canada is a bilingual organization and have staff that can fully serve wish families in both English and French.

Preliminary Information

Are you an active member of the child's healthcare team?*

Yes

*Healthcare professionals may include a physician, nurse, nurse practitioner, social worker, child life specialist or another qualified member of the child’s medical team who is actively involved in the child’s care.

Please select your profession:*

Physician

Nurse

Nurse practitioner

Social worker

Child life specialist

Other

Is the child’s family aware of the referral?*

Yes

Has this child had a wish granted by any other organization?*

Yes

Has a parent or legal guardian already submitted a referral for this child?*

Yes

Information On The Referring Medical Professional

Referring Medical Professional*

First Name Last Name

Email*

Phone*

Hospital/clinic name*

Other

Information on Referred Child

Child's Name*

First Middle Last

Date of birth*

Parent/Legal Guardian #1 name*

First Name Last Name

Information on Referred Child

Child's Name*

First Middle Last

Date of birth*

Age*

Gender*

Male

Female

Self-describe

Child's Preferred Pronouns

Self-describe*

Child’s Primary Residence*

Street Address City Province Postal Code

Was the child born in Canada?*

Yes

Unsure

Children do not need to be born in Canada or hold citizenship to qualify for a wish. Eligibility is based on medical criteria and current residency in Canada.

What is the family’s primary language(s)?

English

French

Other

If other, please specify:*

If the family’s primary language is not English or French, do they have someone who can assist with translation? Please provide their first name, last name, email address and phone number:

Parent(s)/Legal Guardian(s) Information

Parent/Legal Guardian #1 name*

First Name Last Name

Relationship to Child:*

Parent/Legal guardian #1 email**

Parent/Legal guardian #1 phone*

Parent/Legal Guardian #1 Address – same as wish child?*

Yes

Parent/Legal Guardian #1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Legal Guardian #2 Name

First Name Last Name

Relationship to Child:

Parent/Legal Guardian #2 Email

Parent/ Legal Guardian #2 Phone

Parent/Legal Guardian #2 Address – same as wish child?

Yes

Parent/Legal Guardian #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who has legal custody of the child?*

Both parents, same home

Shared custody (separate residences)

Parent/Legal guardian #1 has sole custody

Parent/Legal guardian #2 has sole custody

Unsure

Other

Child's Medical Information

Is the child currently medically stable?*

Yes

Briefly describe the instability or risk of rapid deterioration.*

Hospitalization & ICU Utilization:

Has the child been hospitalized in the last two years?*

Yes

Please indicate: total number of admissions and approximate total days hospitalized.*

Has the child required ICU care for over 48 hours for non-surgical admissions?*

Has the child experienced acute clinical deterioration requiring urgent or emergent care?*

Please describe the child’s motor function*

Independent mobility without limitations (GMFCS Level I)

Independent mobility with limitations (ex. requires wheelchair/ stroller for long distances/tires easily) (GMFCS Level II)

Mobility with assistance or use of mobility devices (e.g., cane, walker, hands-on assistance) (GMFCS Level III)

Limited self-mobility; primarily uses a manual or powered wheelchair (GMFCS Level IV)

Non-mobile; relies fully on wheelchair or supported positioning for mobility (GMFCS Level V)

Timeline:

Should this referral be considered time-sensitive due to declining health?

Yes

Please provide your recommended timeline (e.g., 1 month, 3 months) and explain your reasoning, including any relevant factors such as disease progression, limited window of stability, lack of response to treatment, or upcoming surgery/procedures.*

Has the family been informed of this timeline and are they prepared to move forward quickly?*

Yes

Is the child currently stable enough to participate in a wish?*

Yes

Medical Department*

Medical Condition*

Does the child have severe CF lung disease, defined as FEV1 40% or less when stable and not during an acute exacerbation of CF.

Does the child have FEV1 nearing 40% predicted AND meet any one of the following criteria that are associated with worse outcomes or disease progression? (please provide specific details):

– Referral for lung transplant evaluation
– Rapid rate of decline of FEV1 (provide details) Frequent pulmonary exacerbations in the past 12 months (requiring IV antibiotics and/or admission to hospital)
– Infection with difficult to manage organisms (provide details)
– Pneumothorax
– Massive hemoptysis requiring ICU admission or bronchial artery embolization
– Supplemental oxygen requirement
– Worsening malnutrition despite supplementation (provide details)
– CF related diabetes

Does the child have advanced CF liver disease, defined as one or more of the following (please provide specific details):

– Nodular liver
– Advanced fibrosis (F4)
– Multilobular cirrhosis with or without portal hypertension
– Noncirrhotic portal hypertension
– Referral for liver transplant evaluation

Please specify the child’s diagnosis and provide any relevant details.

Does the child currently have advanced lung disease, defined as FEV1 40% or less when stable and not during an acute exacerbation

Does the patient have FEV1 nearing 40% predicted AND meet any one of the following criteria that are associated with worse outcomes or disease progression? (please provide specific details):

Does the child currently have advanced lung disease, defined as FEV1 40% or less when stable and not during an acute exacerbation

Does the patient have FEV1 nearing 40% predicted AND meet any one of the following criteria that are associated with worse outcomes or disease progression? (please provide specific details):

Medical Condition*

Please specify the child’s diagnosis and provide any relevant details.

Does the child have end-organ involvement or calcinosis? Please describe

Has the child failed or is resistant to multiple medications or therapies for Juvenile Dermatomyositis?

Yes

Has the child had multiple unplanned hospitalizations in the past 12 months for Juvenile Dermatomyositis management?

Yes

Has the child experienced Macrophage Activation Syndrome (MAS/HLH- hemophagocytic lymphohistiocytosis) or ongoing MAS-related issues?

Yes

Has the child failed or is resistant to multiple medications/therapies for JIA/JRA?

Yes

Does the child have significant complications from immunosuppression or other medications, or end-organ involvement? Please describe

Does the child have significant extra-articular manifestations despite treatment?

Yes

Does the child have biopsy-confirmed Class III or greater lupus nephritis?

Yes

Does the child have severe end-organ involvement (e.g., heart, lungs, CNS, kidneys)? Please describe

Has the child had multiple unplanned hospitalizations in the past 12 months for lupus management?

Yes

Does the child have significant complications due to immunosuppression or other medications?

Yes

Medical Condition*

Has the child undergone an allogeneic stem cell or bone marrow transplant? If yes, what was the date of the transplant:

Has the child experienced recurrent, severe, or life-threatening infections? If yes, have any infections required admission to the Pediatric Intensive Care Unit (PICU)?

Please specify the child’s diagnosis and provide any relevant details.

Medical Condition*

Is the child receiving*

Hemodialysis

Peritoneal Dialysis

What is the child’s most recent estimated glomerular filtration rate (eGFR)?

Is the child receiving dialysis*

Yes – Hemodialysis

Yes – Peritoneal Dialysis

Is the child on the transplant list?*

Yes

Describe the child’s overall health status (quality of life, hospital admissions, hyperoxaluria, etc.)

Please specify the child's diagnosis and provide any relevant details

Medical Condition*

Has the child undergone an allogeneic stem cell or bone marrow transplant? If yes, what was the date of the transplant:

Does the child require regular, chronic blood transfusions? (monthly)

What type of Hemophilia does the child have?

Hemophilia A

Hemophilia B

Does the child need weekly (or more often) IV Factor infusions due to disease severity or because other treatment options (such as emicizumab) are not suitable for them?

Yes

Has the child experienced repeated serious or life-threatening bleeding episodes in the past 12 months?

Has the child developed chronic inhibitors that interfere with standard factor replacement therapy?

Has the child started systemic therapy for Langerhans Cell Histiocytosis (e.g., vinblastine and steroids)?

Has the child received an allogeneic stem cell transplant or IST for severe aplastic anemia? Provide details

Has the child experienced a reactivation or relapse of Langerhans Cell Histiocytosis requiring medical treatment? (please describe)

Does the child have Langerhans Cell Histiocytosis with any endocrinopathies?

Has the child undergone an allogeneic stem cell or bone marrow transplant? If yes, what was the date of the transplant:

How would you describe the child’s current disease severity?

Severe and unstable (frequent crises / major complications)

Moderate (some complications (e.g., vaso-occlusive crises – manageable without major interventions)

Mild

Has the child experienced any severe or life-threatening complications related to sickle cell disease? Please describe (examples: number of ICU admission for acute chest syndrome, stroke with long-term impairment, frequent severe vaso-occlusive crises)

Is the child on regular(monthly) transfusions?

Yes

What subtype of Von Willebrand Disease does the child have?

Does the child have severe impairments related to previous bleeding incidents?

Please specify the child’s diagnosis and provide any relevant details.

Medical Condition*

Does the child currently have severe hypertrophic, restrictive, dilated and/or arrhythmogenic cardiomyopathy?*

What is the child’s specific congenital heart defect diagnosis (e.g., Hypoplastic left heart syndrome, single-ventricle physiology)?*

Has the child had an arrest?*

Yes

Has the child had, or is the child planned to have, an implantable cardioverter defibrillator (ICD)? If an ICD is not an option, does the child have significant symptoms despite maximal medical therapy?*

Does the child also have Pulmonary Atresia and Major Aortopulmonary Collaterals?*

Yes

Please specify the child’s diagnosis and provide any relevant details.*

Is the child currently on IV or subcutaneous therapy for PH?*

Yes

Does the child currently have any of the following clinical or diagnostic findings?

Clinical evidence of RV failure

WHO functional class III or IV

Elevated serum NT-pro BNP for age >1200 pg/ml

Echocardiography demonstrating severe RA or RV enlargement, RV systolic dysfunction, or pericardial effusion

Abnormal cardiac catheterization (provide details)*

Please specify the child’s diagnosis and provide any relevant details.*

Medical Condition*

Does child have moderate to severe liver failure (child pugh score of B or C or other objective score)? If no, describe.

Does child have severe complications (portal hypertension, episodes of cholangitis?

Has child received a liver transplant or been referred for a liver transplant?

Did the child have a colectomy in the context of IBD?

Does the child have major bowel resection?

Have there been multiple unplanned hospitalizations in the past 12 months for IBD, including complications such as severe bleeding or need for transfusion? If so, how many times in the past 12 months?

Has the child failed multiple therapies for IBD and/or experienced serious complications related to immunosuppression or medications?

Are there extensive severe extra-intestinal manifestations?

Does child have moderate to severe liver failure (child pugh score of B or C or other objective score)? If no, describe.

Has child received a liver transplant or been referred for a liver transplant?

Please specify the child’s diagnosis and provide any relevant details.

Medical Condition*

Has the child undergone an allogeneic stem cell or bone marrow transplant? If yes, what was the date of the transplant:

Is the child currently symptomatic?

Yes

Does the child have heart anomalies that have required or will require surgical intervention?

Does the child have major gastrointestinal dysfunction requiring medical or enteral feeding support?

Did the child show any symptoms of Hunter syndrome/MPS before age 3? If so, please specify which symptoms.

Is there evidence of a progressive course, including neuroregression? If yes, at what age did progression begin?

Is the child currently neurologically symptomatic?

Yes

What is the child’s specific mitochondrial diagnosis, and what are the primary systems affected (e.g., neurologic, cardiac, muscular)?

Does the child have a symptomatic brain tumor or type 1 plexiform neurofibroma that requires targeted therapy for NF1? If yes, please describe the therapy being received (e.g., IV chemotherapy, oral chemotherapy, etc.)

Does the child have severe arteriopathy, including intractable renovascular hypertension or severe cerebrovascular disease (with or without stroke)?

Describe the child's type/severity of OI

Does the child have chronic or degenerative pulmonary complications (e.g., restrictive lung disease, recurrent pneumonia)?

Yes

Please specify the child’s diagnosis and provide any relevant details.*

Medical Condition*

Does the child have significant hormone or endocrine problems related to the tumour that require treatment?

Does the child have major functional problems, such as paralysis or other serious neurologic impairments, caused by the tumour?

Has the child ever required a major brain surgery (craniotomy) for their tumour? If yes, have they needed more than one surgery?

Please specify the child’s diagnosis and provide any relevant details.

Medical Condition*

What complications do they have related to Friedreich's Ataxia?

Does the child currently have severe hypertrophic, restrictive, dilated and/or arrhythmogenic cardiomyopathy?

Does the child have any of the following Spina Bifida related criteria? (Please provide specific details):

– Presence of a VP shunt, list any complications (shunt infections, shunt revisions)
– Presence of a Cecostomy
– Presence of a Mitrofanoff
– History of chronic kidney disease (please indicate stage)
– Hospitalizations related to urinary tract infections (UTIs) (please indicate frequency)

When did the event/injury take place?

Does the child have cerebral ALD (neurologic involvement)?

Yes

Has the child undergone an allogeneic stem cell or bone marrow transplant? If yes, what was the date of the transplant:

Does the child have lasting neurologic or functional impairments affecting mobility, feeding, communication, or other activities of daily living as a result of the injury?

Please specify the child’s diagnosis and provide any relevant details.

Is the child symptomatic?

Yes

Does the child have rapidly progressive moyamoya disease?

Yes

Has the child experienced recurrent strokes that result in neurologic or functional impairment?

Yes

Has the child undergone surgery for moyamoya?

Yes

Is the child symptomatic?

Yes

Please specify the SMA type:

Has the child been able to recover to baseline after an episode/surgery?

Does the child have tumors of the brain and/or spinal cord that requires targeted therapy? If yes, please describe the therapy being received (e.g., IV chemotherapy, oral chemotherapy, etc.)

Does the child have major systemic complications, such as renal failure from the TS, angiomyolipomas or neuroendocrine tumors?

Medical Condition*

Please summarize the child’s condition including disease extent, complications, infections, treatments, hospitalizations, and any treatment failures.

Please specify the child’s diagnosis and provide any relevant details.

Has the child had any major open heart surgeries? If so, how many and what were they?*

Has the child had any percutaneous procedures? Please describe.*

Has the child had significant complications from cardiac surgery?*

Yes

Does the child have significant heart failure affecting daily life such as severe ventricular dysfunction that persist in time?*

Yes

Does the child have any implanted cardiac devices (e.g., Implantable Cardioverter Defibrillator [ICD] or Ventricular Assist Device [VAD])?*

Yes

Does the child require prolonged parenteral (TPN) support (for period of 6 months or longer)?*

Yes

Date of Diagnosis*

Is the child currently receiving, or have they previously received, IV chemotherapy infusions or radiation treatment for this condition?*

Yes

Please Describe*

Please Describe Treatment*

Is the child dependent for any or all activities of daily living (ADLs)?*

Yes

Please describe (bathing, dressing, toileting, feeding)*

Please summarize the child’s condition including disease extent, complications, infections, treatments, hospitalizations, and any treatment failures.*

Please specify the child’s diagnosis and provide any relevant details.*

Feeding and Respiratory History:

How is the child fed? (Please specify, e.g., orally, G-tube, GJ-tube, NG/ND, etc.)*

Has the child ever required emergency visits or hospitalizations due to respiratory exacerbations (including pneumonia)? If yes, describe with frequency, duration, and severity (level of intervention/treatment required).

Seizures and Dystonia

Does the child have dystonia?

Yes

Has the child experienced inadequate dystonia control despite trials of at least two dystonia medications? (Note medication ineffectiveness must be due to lack of efficacy and not for side effects/tolerability) If yes, please list medications.

Does the child have seizures?

Yes

What type of seizures does the child have? (e.g., tonic, atonic, tonic-clonic)?

Has the child experienced inadequate seizure control despite trials of at least two anti seizure medications? (Note medication ineffectiveness must be due to lack of efficacy and not for side effects/tolerability) If yes, please list medications.

Has the child continued to have repeated breakthrough seizures requiring rescue medications and/or unplanned hospital admissions (e.g., approximately one event per month)?

Does the child have a Vagus Nerve Stimulator (VNS) or Deep Brain Stimulator (DBS)?

Yes

Do they have epileptic encephalopathy?

Yes

Have they had surgery for epilepsy? If yes, has the child experienced seizures since the surgery?

Are they on a ketogenic diet?

Yes

Multisystem Involvement:

Does the child have any involvement of other organ systems related to their condition (e.g., heart, lung, kidneys, endocrine, or metabolic)?*

Yes

Please describe*

Technology:

Is the child dependent on medical technology, implanted devices, or direct instillation of therapies into the central nervous system to survive? Please specify the type and duration of support, if applicable (e.g., tracheostomy, invasive ventilator, intrathecal baclofen pump, etc.)

We're sorry

We’re sorry, but to submit a referral, you must be an active member of the wish child’s healthcare team, the family must be aware of the wish, the potential wish child has to be between the ages of 3 and 17 years and not have had a wish granted by any other organization.

If you have any questions, please contact us at referachild@makeawish.ca.

Please share any additional relevant medical details or secondary diagnoses.

Treating physician’s name (if different from person completing this referral)

Your Signature*