Make a Referral | Chix 4 a Cause LTD

REQUEST A GIFT OF LOVE

We know that fighting cancer is tough enough without having to deal with the realities of daily life. That's why we are happy to help with a one time Gift of Love to ease some of the burden -- regardless of financial status. To qualify for a gift of love, the patient must reside in southeastern Wisconsin and currently be receiving treatments.

Out of our service area? We can't help with financial support beyond Southeastern Wisconsin, but we CAN ship Gift of Love boxes nationwide! They are bursting with emotional support items to help during your time of need. Click here to learn more.

Tell Us About the Person You are Referring

First Name of Recipient

Last Name of Recipient

Recipient's Email

Recipient's City

Recipient's County

Date of Diagnosis:

Recipient's Phone Number

Did this person consent to us contacting them?

Yes

No

In order for us to contact someone, you must first let them know you have referred them to Chix 4 a Cause.

Best time to contact:

Morning

Afternoon

Evening

Type of Cancer

Other Cancer Type

Currently in treatment?

Yes

No

A person must be actively receiving treatment in order to be eligible.

What would you like us to know about the person you're referring?

Tell Us About You

First Name

Last Name

Email

Please note: Requests that are out of our service area cannot be fulfilled at this time as we only currently serve Southeastern Wisconsin. However, Gifts of Love boxes can be shipped nationwide.

Thank you for your request.

We will reach out to the person you referred shortly.