Self Referral to Hospice Community Services

Self referral to hospice community services

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

Do you or the person you care for have a palliative diagnosis?(Required)

Yes

No

A referral has not been created for you and we encourage you instead to seek support from your GP.

Are you a patient or a carer / family member?(Required)

I am the patient or I am filling this in on behalf of the patient

I am a carer or family member

Patient's Details

Patient's name(Required)

First Last

Patient's date of birth(Required)

Patient's telephone number(Required)

Patient's address(Required)

Street Address Town / City County Postcode

Patient's religion

Carer or Family Member's Details

Carer's name(Required)

First Last

Carer's date of birth(Required)

Carer's relationship with patient(Required)

Carer's telephone number(Required)

Carer's address(Required)

Street Address Town / City County Postcode

Diagnosis of the Patient

Diagnosis(Required)

Date of diagnosis(Required)

Detail any current issues

Reason for referral

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

Someone to support and listen to me about my caring role

Information and support to help me cope with my caring role

Support to discuss any financial concerns and access to resources

Complementary therapy

Assessment for counselling

Caring Well - Thinking Well programme

Walking Group

GP's Details

GP name

GP practice

GP telephone number

Communication Needs

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

Is an interpreter required?

Yes

No

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

Legal Agreements

Signature (type your name)(Required)

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Date of Submission

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