Professional Referral to Hospice Community Services

1Eligibility

2Contacts

3Diagnosis

4Referrer

5Status

6GP / Comm Details

7Legals

Professional referral to hospice community services

CONFIDENTIAL All relevant fields must be completed fully as an incomplete form will lead to a delay in processing.

Which of the following describes the reason for this referrall?(Required)

The patient has a palliative diagnosis

The person is caring for someone with a palliative diagnosis

Neither

This form is only suitable for referring patients or carers of patients with a palliative diagnosis. A referral has not been created.

Carer Details

Carer's name(Required)

First Last

Carer's relationship with patient(Required)

Carer's date of birth(Required)

Day

Month

Year

Carer's telephone number(Required)

Carer's address(Required)

Street Address Town / City County Postcode

Carer's H&C no.

(if available)

Reason for carer referral(Required)

Carer support sessions

Financial signposting, budgeting and support

Complementary Therapy

Assessment for counselling - please note that a holistic needs assessment will be completed by a member of the Community Outreach Team in the first instance. This will be by either a Social Worker or a Nurse. The assessment outcome will inform the suitable level of intervention provided by our team.

Caring Well - Thinking Well programme

Walking Group

Patient's Details

Patient's name(Required)

First Last

Patient's date of birth(Required)

Day

Month

Year

Patient's telephone number(Required)

Patient's address(Required)

Street Address Town / City County Postcode

Patient's religion

Patient's H&C no.

(if available)

Patient's no of dependents under 18 years

Reason for patient referral(Required)

The Community Service Team consists of Nurses, Social Workers, Chaplains, Physio, Complementary Therapists and Counsellors.

6 week Living Well - Thinking Well programme

1-2-1 support of patient in relation to their illness and help identify coping strategies

Spiritual support and guidance

Information and support about talking to children about illness or death

Financial signposting, budgeting and support

Complementary therapy

Walking Group

Next of Kin Details

Next of kin name(Required)

First Last

Next of kin address(Required)

Street Address Town / City County Postcode

Next of kin phone number(Required)

Diagnosis of the Patient

Diagnosis(Required)

Is patient aware of diagnosis?(Required)

Yes

Date of diagnosis(Required)

Day

Month

Year

Detail any current issues

(enter details of unresolved complex physical, social, psychological and spiritual symptoms including concerns affecting carer/family, give details of what interventions you have trialled)

Relevant past medical history

Known allergies

Referrer's Details

Name of referrer(Required)

First Last

Job role(Required)

Referrer telephone number(Required)

Referrer email address

ELCOS status(Required)

Should/ may be years A

Could be last year B

Possibly months C

Probably last few weeks/days/hours D

Patient location(Required)

Where is the patient currently at (please select one option)

Home

Nursing Home

Hospital

Other

Patient mobility(Required)

Mobile

Mobile with difficulty (stiffness, pain)

Mobile with equipment, assistance or aids

Immobile

GP Details

GP name(Required)

GP practice(Required)

GP telephone number(Required)

Communication Needs

Are there any communication needs we need to be aware? e.g. speech difficulties

Is an interpreter required?

Yes

Detail the interpreter needs (language, dialect, speech recognition)(Required)

Consent

Is the GP aware of this referral?(Required)

Yes

Has consent been obtained for this referral?(Required)

Yes

Legals / Authorisation

Signature (type your name)(Required)

This field is hidden when viewing the form

Date of Submission

DD dash MM dash YYYY

Your email address

You must provide an email address if you'd like to receive a copy of this form.

I declare that the information that I have provided is correct.(Required)

Yes

Consent(Required)

By submitting this form I agree for Evora to store my details and contact me by phone and/or email with further information and questions regarding referrals.

I agree.

Professional Referral to Hospice Community Services

Professional referral to hospice community services

Carer Details

Patient's Details

Next of Kin Details

Diagnosis of the Patient

Referrer's Details

GP Details

Communication Needs

Consent

Legals / Authorisation

Admissions and Referrals

Self Referral to Hospice Community Services

Admissions and Referrals