Please complete all fields of the referral form – incomplete forms will be rejected and returned to the referrer

Consent to referral - Referrals to Hospice in the Weald should only be made with the patient’s consent and in the knowledge that their medical record will be viewed by the relevant team. If the patient is unable to provide consent, due to capacity or condition, we request that: - consent is provided by the person/s holding a LPA for the patient’s Health and Welfare (please provide details/copy of LPA) OR - the responsible Healthcare Professional making the referral is acting in the patient’s Best Interest and/or provides details of a Best Interest Meeting.

Is the patient aware of the referral ?(Required)

Does the patient consent to being referred to Hospice in the Weald ?(Required)

The reason you are referring this patient to the Hospice ?(Required)

What are the patient's expectations of the referral ?(Required)

What care and support does the patient you are referring to the Hospice in the Weald require?(Required)

Outreach Service: offering Specialist Palliative Care symptom and related medication advice, assistance with decision making and Advance Care Planning.

In-Patient Care: for symptom control that is difficult to manage at home, as well as end of life care for those patients in their last days.

Living Well: for those people with life limiting conditions who would benefit from our Living Well therapies, offering a personalised programme to help people achieve what is important to them.

Occupational Therapy & Physiotherapy: for support with reduced mobility, weakness, shortness of breath and pain – to help maintain independence.

Emotional & Spiritual Support: for talking therapies, providing patients and their loved one's opportunity to explore emotions and find peace.

Childrens & Young Persons Service – offering specialist nursing care to those with life limiting & life-threatening conditions.

External Healthcare providers currently associated in the patients care (inl. details)

District Nurses

Community OT

Complex Care Nurse

Specialist Nursing Team

Social worker

Community Physio/OT

Mental Health Team

Respiratory Team

Other

Patient Details(Required)

Title

First Name

Surname

Date of Birth

NHS no

Ethnicity

Primary Diagnosis

Prognosis

Patient's Current Location

Patient's Registered Home Address(Required)

House/flat name or number

Address line 1

Address line 2

Town

Postcode

County

Patient's GP Name:

GP Surgery & Address:

GP telephone

Is the patient able to communicate via telephone ?(Required)

Yes

Phone(Required)

Alternative Contact Information(Required)

e.g friend, partner, family member (non-professional) please provide details:

Name

Relationship to Patient

Contact Number

GP Name

GP Surgery & Address

GP Telephone

Supporting clinical information

In order to help us assess the patient’s needs and suitability to Hospice care – please provide us with copies of the following information: - Brief Patient Summary and copies of recent consultant / clinic letters - Recent test results (including diagnostic testing e.g. MRI, X-Ray etc.) - Recent blood test result We aim to assess all patients within 14 working days of referral receipt. *If you are concerned that your patient requires an urgent assessment, please call a member of the team on 01892 820515.

Are there any potential risks or considerations we should be aware of associated with visiting the patient? (e.g. safeguarding, firearms, pets)

Referrer's Details(Required)

Your details or the person referring this patient

Title

Name

Place of Work

Contact Number

Email Address