Antenatal referral

Please note - fields marked with * are mandatory.

Do those with parental responsibility consent to this referral*

Yes

No

We're sorry, but we are unable to proceed with this referral. Please complete this form once consent has been provided by those with parental responsibility.

About you

Please enter your professional details.

Your name*

First Last

Job title*

Your organisation*

Your daytime telephone number*

Your email*

What is your involvement with the child/family you are referring?*

Baby's details

Gender (if known)

Male

Female

Baby's name (if known)

Expected due date*

Planned date of delivery

Type of delivery

Place of delivery

Diganosis*

Prognosis*

Have any Advanced Care planning discussions taken place?*

Yes

No

Please detail who was present during these conversations and when they took place:*

Please consider having an advanced care planning discussion.

About the parents

Mother's name*

First Last

Mother's date of birth*

Mother's NHS Number*

Mother's daytime telephone number*

Alternative telephone number

Please specify who's number this is

Mother's email address

Mother's address*

Street Address Address Line 2 Town County Post Code

What is the mother's first language?*

Is an interpreter required?

Yes

No

Mother's ethnic group

Mother's religion

Would you like to add another parent/guardian?*

Yes

No

Parent/Guardian's Name*

First Last

Parent/Guardian's relationship to the child*

Parent/Guardian's daytime telephone number*

Parent/Guardian email address*

Parent/Guardian's address (if different from above)

Please complete this if different from the mother's address

Street Address Address Line 2 Town County Post Code

What is the parent/guardian's first language?*

Is an interpreter required?

Yes

No

Parent/Guardian ethnic group

Pleas complete this is if different from the child's ethnic group

Parent/Guardian's religion

Other professionals involved with the family

Do those with parental responsibility consent for us to contact the professionals listed below in order to gain accurate information?*

Yes

No

Name of General Practitioner (GP)

Practice address

Street Address Address Line 2 Town Couty Post code

Practice telephone number

Consultant name

First Last

Consultant title/area of practice

Consultant hospital

Consultant telephone number

Please provide details of any other professionals you think we should be aware of

Include social workers, health visitors, midwives, dietician and other agencies

Background medical information

Please provide more details about why you are making this referral, including medical history*

Please let us know about any family/social history, education etc

Social Concerns

Are there any safeguarding concerns?*

Yes

No

Please provide details*

Are there any other social issues we should be aware of?*

Yes

No

Please provide details*

Consent

In order to provide safe and effective care, Brian House Children's Hospice will need to obtain or share the child's up to date personal details and general medical and social care information, including clinic letters, copies of prescriptions (FP10), emergency care plans and advance care plans from other professionals, including (but not limited to) schools, community teams, GPs, hospitals, local authorities and/or Place-based Partnerships.

Do those with parental responsibility consent to Brian House Children's Hospice to seek and share health and social care information as outlined above?*

Yes

No

Please note that by making this referral it may be necessary for us to request further medical information as necessary.

Consent

I confirm that the information provided on this form is correct and can be retained by Brian House Children's Hospice in the strictest confidence, only to be used for the purposes for which it has been provided.

I agree

Please contact Brian House Children's Hospice if any details change in order for us to update your referral. Call 01253 952589 or email trinity.brian.house@nhs.net

About you

Baby's details

About the parents

Other people in the household

Other professionals involved with the family

Background medical information

Social Concerns

Consent