Referrals

Home Referrals

We’re here to help, whatever you need

Referrals can be made to each of our services, helping patients and their friends and family access the right care at the right time. Referrals are made using our online referral form, with each service having its own dedicated form and questions tailored to that department. If you are submitting a referral for more than one service, please complete a separate form for each service.

There are several ways a referral can be made. This may be through a healthcare professional, via a GP, through self-referral, or on behalf of a friend or family member.

For those who are unable to access the internet, paper referral forms are available. To request a paper copy, please contact our Clinical Administration Team on 01254 916924 or 01254 965864, and they will be happy to help.

Referrals for Hospice at Home, Clinical Nurse Specialists and Physiotherapy can be made through healthcare professionals, such as your GP or District Nurse. Unfortunately, we do not accept self-referrals for these services.

"*" indicates required fields

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Are you referring yourself or someone else?*

Self

On behalf of someone else

Referrer Details

Referrer Name*

Referrer Relationship

Please specify Other*

Referral Organisation*

Referrer Contact Number*

Referrer Email Address*

Referrer Signature*

Date of Referral*

DD slash MM slash YYYY

Consent for Referral

Please Note: We cannot accept a referral for a patient who has capacity and does not consent.

If NO, tick here to confirm that the decision to refer is in the patient’s best interests)

Patient Details

Sex Assigned at Birth

Identifying Gender*

Self-describe*

Title*

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address* County* Post Code*

Telephone Number*

Does the patient have an email address?*

Yes

Email Address*

NHS Number*

Ethnicity*

GP Name and Practice*

Please specify Other*

Consent for Sharing*

Yes

Agreement to share personal/medical info with relevant services*

Yes

Armed Forces Community Status*

Safeguarding Concerns*

Yes

Please specify Safeguarding Concerns*

Communication Difficulties*

Yes

Please specify Communication Difficulties*

Interpreter Needed*

Yes

Current Services/Professionals Involved*

Yes

Please specify Current Services/Professionals Involved*

Please select the service you are referring to*

Please note: if you are referring to more than one service, you must complete a separate referral form for each service

Please note, referrals for Physiotherapy can only be made through healthcare professionals, such as your GP or District Nurse.

Inpatient Unit

Patient’s location at time of referral*

Describe the patient’s diagnosis*

Describe the patient’s medical history*

Describe how your patient’s complex needs mean that an IPU admission is required at this present time*

Describe the patient’s current problems/symptoms*

Examples include pain, agitation/confusion, breathing, nausea & vomiting, emotional distress, carer distress.

What medication is currently being prescribed?*

Include names of medication, the dose, and how many PRNs were required in the past 48 hours

Does the patient have a preferred place of care?*

Yes

Please specify preferred place of care*

Does the patient have a preferred place of death?*

Yes

Please specify preferred place of death*

Does the patient have a DOLS in place?*

Yes

Please specify DOLS*

Does the patient have a DNACPR in place?*

Yes

Please specify DNACPR*

Does the patient have any complex wounds or pressure damage?*

Yes

Please specify complex wounds or pressure damage*

Does the patient have an Advanced Care Plan in place?*

Yes

Please specify Advanced Care Plan*

Does the patient have any Anticipatory (just in case) medications?*

Yes

Please specify Anticipatory medications*

Does the patient have a care package in place?*

Yes

Please specify care package*

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Hospice at Home

Referrals for Hospice at Home can be made through healthcare professionals, such as your GP or District Nurse. Unfortunately, we do not accept self-referrals for these services.

Describe the patient’s diagnosis*

Is the Patient aware of their diagnosis*

Yes

Is the Patient aware of their prognosis*

Yes

Any other significant conditions, current problems or symptoms?*

Yes

Please describe other significant conditions, current problems or symptoms*

Describe the patient’s medical history*

Please describe what you expect from the Hospice at Home service*

Is this referral to support a hospital discharge?*

Yes

Please identify any Psychological, Emotional, Spiritual, Cultural needs or insights*

Please include details of awareness of diagnosis and prognosis, capacity, fears, anxieties, faith and cultural personal importances.

Please identify any Physical needs*

Please include any communication difficulties, mobility, adapted diet/fluids, daily needs, continence, and symptoms.

Please identify any family, friend or carer distress or needs*

Please include details of any emotional and practical needs.

Please identify any current care arrangements and concerns*

Please include details of approved CHC funding, established or requested PoC.

Are there any identified risks for professionals?*

Yes

Please describe identified risks for professionals*

For example, pets, unpredictable behaviour, hostile visitors, any access issues.

Are there any identified risks for patients?*

Please include details such as swallowing difficulties, oxygen needs, or any safeguarding concerns not previously mentioned

Yes

Please describe identified risks for patients*

Please include details such as any safeguarding concerns, falls, swallowing difficulties, oxygen needs etc

Are there any issues locating/accessing the property?*

Yes

Please describe issues locating/accessing the property*

Please list any key safes, stairs, or parking issues

Does the patient or anyone at the house smoke?*

Yes

Please describe*

Are there any hazards, risks or circumstances at the property that require management?*

Yes

Please describe any hazards, risks or circumstances at the property that require management*

Please provide details of the fire risk/oxygen

Does the patient have a preferred place of care?*

Yes

Please describe the patient's preferred place of care*

Does the patient have a preferred place of death?*

Yes

Please describe the patient's preferred place of death*

Does the patient have a DNACPR in place?*

Yes

Please describe the patient's DNACPR*

Does the patient have an Advanced Care Plan in place?*

Yes

Please describe the patient's Advanced Care Plan*

Does the patient have any Anticipatory (just in case) medications?*

Yes

Please describe the patient's Anticipatory medications*

Does the patient have a care package in place?*

Yes

Please describe the patient care package*

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Clinical Nurse Specialists

Referrals for Clinical Nurse Specialists can be made through healthcare professionals, such as your GP or District Nurse. Unfortunately, we do not accept self-referrals for these services.

Describe the patient’s diagnosis*

Is the Patient aware of their diagnosis?*

Yes

Is the Patient aware of their prognosis?*

Yes

Any other significant conditions, current problems or symptoms?*

Describe the patient’s medical history*

Describe the patient's current problems, any uncontrolled symptoms, distress or complex issues?*

Please describe the problems/distress

What has already been tried to manage the above problems, symptoms and distress?*

Please describe the patient’s current plan and give examples for what has already been tried

Does the patient have a syringe driver in place?*

Yes

Please describe*

Are there any identified risks for professionals?*

Yes

Please describe identified risks for professionals*

For example, pets, unpredictable behaviour, hostile visitors, any access issues

Are there any identified risks for patients?*

Please include details such as swallowing difficulties, oxygen needs, or any safeguarding concerns not previously mentioned

Yes

Please describe identified risks for patients*

Please include details such as any safeguarding concerns, falls, swallowing difficulties, oxygen needs etc

Are there any issues locating/accessing the property?*

Yes

Please describe issues locating/accessing the property*

Please list any key safes, stairs, or parking issues

Does the patient or anyone at the house smoke?*

Yes

Please describe who smokes at the house*

Are there any hazards, risks or circumstances at the property that require management?*

Yes

Please describe the hazards, risks or circumstances at the property that require management*

Please provide details of the fire risk/oxygen

Does the patient have a preferred place of care?*

Yes

Please state the patient's preferred place of care*

Does the patient have a preferred place of death?*

Yes

Please state the patient's preferred place of death*

Does the patient have a DNACPR in place?*

Yes

Please specify DNACPR*

Does the patient have an Advanced Care Plan in place?*

Yes

Please specify Advanced Care Plan*

Does the patient have any Anticipatory (just in case) medications?*

Yes

Please specify Anticipatory medications*

Does the patient have a care package in place?*

Yes

Please specify care package*

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Creative & Support Therapies

Describe the patient’s diagnosis*

Is the Patient aware of their diagnosis?*

Yes

Is the Patient aware of their prognosis?*

Yes

Please confirm that this is a palliative/ life-limiting illness/diagnosis?*

Yes

Any other significant conditions, current problems or symptoms*

Describe the patient’s medical history*

Describe what is happening with the patient at present and why you have chosen to refer them to the Creative & Support Therapies service?*

Do you have any issues or concerns that you believe the Creative & Support Therapies service can help to address?*

Does the patient have any Mobility issues?*

Yes

Please describe the patient's Mobility issues*

Does the patient have any Medical equipment that we need to be aware of?*

Yes

Please list the patient's Medical equipment*

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Bathing

Describe the patient’s diagnosis*

Is the Patient aware of their diagnosis?*

Yes

Is the Patient aware of their prognosis?*

Yes

Please confirm that this is a palliative/ life-limiting illness/diagnosis??*

Yes

Any other significant conditions, current problems or symptoms?*

Describe the patient’s medical history*

Describe what is happening with the patient at present and why you have chosen to refer them to the Bathing service?*

Do you have any issues or concerns that you believe the Bathing service can help to address?*

Does the patient have any Mobility issues?*

Yes

Please describe the patient's Mobility issues*

Does the patient have any Medical equipment that we need to be aware of?*

Yes

Please list Does the patient's Medical equipment*

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Complementary Therapy

Describe the patient’s diagnosis*

Is the Patient aware of their diagnosis?*

Yes

Is the Patient aware of their prognosis?*

Yes

Please confirm that this is a palliative/ life-limiting illness/diagnosis?*

Yes

Any other significant conditions, current problems or symptoms?*

Describe the patient’s medical history*

Describe what is happening with the patient at present and why you have chosen to refer them to the Complementary Therapy service?*

Do you have any issues or concerns that you believe the Complementary Therapy service can help to address?*

Does the patient have any Mobility issues?*

Yes

Please list the patient's Mobility issues*

Does the patient have any Medical equipment that we need to be aware of?*

Yes

Please list the patient's Medical equipment*

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Physiotherapy

Referrals for Physiotherapy can be made through healthcare professionals, such as your GP or District Nurse. Unfortunately, we do not accept self-referrals for these services.

Describe the patient’s diagnosis*

Any other significant conditions, current problems or symptoms*

Describe the patient’s medical history*

Describe what is happening with the patient at present and why you have chosen to refer them to the Physiotherapy service?*

Do you have any issues or concerns that you believe the Physiotherapy service can help to address?*

Does the patient have any respiratory difficulties?*

Please include if the patient has an oxygen machine or CPAP

Does the patient have any Medical equipment that we need to be aware of?*

Yes

Please list the patient's Medical equipment*

Please describe the patient’s current mobility level*

Do they have any walking aids? Have they had any recent falls?

Does the patient have any cognitive impairment?*

Yes

Please describe the patient's cognitive impairment*

Please include any mental health issues that could affect participation

Are there any identified risks for professionals?*

Yes

Please specify the identified risks*

For example, pets, unpredictable behaviour, hostile visitors, any access issues

Are there any identified risks for patients?*

Yes

Please specify the identified risks*

Please include details such as any safeguarding concerns, falls, swallowing difficulties, oxygen needs etc

Are there any issues locating/accessing the property?*

Yes

Please describe the issues locating/accessing the property*

Please list any key safes, stairs, or parking issues

Does the patient or anyone at the house smoke?*

Yes

Please describe*

Are there any hazards, risks or circumstances at the property that require management?*

Yes

Please describe any hazards, risks or circumstances at the property that require management*

Please provide details of the fire risk/oxygen

Does the patient have an LPA for Health & Welfare?*

Yes

Please describe the patient's LPA for Health & Welfare*

Does the patient have an LPA for Finance & Property?*

Yes

Please describe the patient's LPA for Finance & Property*

Does the patient have a GSF Status?*

Yes

Please describe the patient's GSF Status*

Upload any files relevant to this referral

Max. file size: 128 MB.

Counselling

Does the person being referred have a palliative/life-limiting illness?*

Yes

Please describe the illness below*

Please confirm that the person being referred is a friend or family member of someone with a palliative/life-limiting illness*

Yes

Please state your connection to the patient*

Is the person being referred a patient currently on the Inpatient Unit?*

Yes

Is the person being referred a family member or friend of someone who is currently on the Inpatient unit?*

Yes

If yes, please state your connection to the patient*

Does the patient or the person being referred have a disability?*

Yes

Please describe below*

Describe the patient’s or the person being referred’s medical history*

Does the patient or the person being referred have any Mobility issues?*

Yes

Please describe the patient's Mobility issues*

Does the patient or the person being referred have any Medical equipment that we need to be aware of?*

Yes

Please list the patient's Medical equipment*

Do you have any issues or concerns that you believe the Counselling service can help to address?*

Are there any other healthcare professionals involved in your or the patient’s individual care/support?*

Yes

Please list any healthcare professionals who are involved in your or the patient’s individual care/support*

Does the person being referred or the patient receive any other formal counselling with another service or provider?*

Yes

Please give details of other formal counselling*

Does the person being referred or the patient suffer from a mental health condition, including anxiety or depression?*

Yes

Please list details of the mental health condition*

Does the person being referred or the patient suffer from self-harm or thoughts of suicide?*

Yes

Please describe how the patient patient suffers from self-harm or thoughts of suicide*

Does the person being referred or the patient have any difficulties with alcohol or drug use?*

Yes

Please list any difficulties with alcohol or drug use*

Does the person being referred or the patient suffer from the risk of others, such as domestic abuse or financial abuse?*

Yes

Please describe*

Upload any files relevant to this referral

Max. file size: 128 MB.

Bereavement

Please describe the relationship you had with the person who died*

Please write the month and year that the person died*

Do you or the person being referred have a disability?*

Yes

Please describe below*

Do you or the person being referred have any Mobility issues?*

Yes

Please describe any Mobility issues*

Do you or the person being referred have any Medical equipment that we need to be aware of?*

Yes

Please list any Medical equipment*

Describe yours or the person being referred's medical history*

Do you have any issues or concerns that you believe the Bereavement service can help to address?*

Are there any other healthcare professionals involved in yours or the person being referred’s individual care/support?*

Yes

Please list any healthcare professionals who are involved in your or the person’s individual care/support*

Do you or the person being referred receive any other formal counselling with another service or provider?*

Yes

Please give details of other formal counselling*

Do you or the person being referred suffer from a mental health condition, including anxiety or depression?*

Yes

Please list details of the mental health condition*

Do you or the person being referred suffer from self-harm or thoughts of suicide?*

Yes

Please describe how the patient patient suffers from self-harm or thoughts of suicide*

Do you or the person being referred have any difficulties with alcohol or drug use?*

Yes

Please list any difficulties with alcohol or drug use*

Do you or the person being referred suffer from the risk of others, such as domestic abuse or financial abuse?*

Yes

Please describe*

Upload any files relevant to this referral

Max. file size: 128 MB.

Referrals

We’re here to help, whatever you need

Referrer Details

Patient Details

Inpatient Unit

Hospice at Home

Clinical Nurse Specialists

Creative & Support Therapies

Bathing

Complementary Therapy

Physiotherapy

Counselling

Bereavement

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