Care Package Request Form

Request a care package

Do you know of someone in need of a care package? We ask a lot of questions up front so we can verify the recipient’s info before we send anything. Please read through the form so you can be sure you have all the information. We always ship the packages, and we will ship only within the US. We will get back to you within 7 days of your request. If you have any questions, please contact us.

Info about the patient Info about the patient

Patient's name

Patient's age

Patient's diagnosis

Patient's date of diagnosis

Tell us about yourself Tell us about yourself

Your name

Your relationship to the patient

Your email

Your phone

Patient's social worker or case manager Patient's social worker or case manager

Name of the patient's social worker or case manager

Social worker/case manager's PROFESSIONAL/HOSPITAL email address

Social worker or case manager's work phone

Do you give Team Mathias permission to contact this person?