Self-referral - Brian House Children’s Hospice

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 own details.

Your name*

First Last

Your daytime telephone number*

Your email*

Are you:*

The child's parent

Relative

Guardian

Other

Please describe your relationship to the child you are referring*

What support does this child/family need?*

Click all that apply

Daytime respite care

Night time respite care

Group Support (including siblings and play sessions)

Who is the support for?

How old is the child/young person who needs our care?*

0-16

17-19

Is the child still under the care of paediatric services?*

Yes

No

We're sorry, but this child does not meet our eligibility criteria. Please click here to find other services which may be able to support them.

Child's name*

First Last

Child's date of birth*

Child's gender*

Male

Female

Other/prefer not to say

Child's address*

Street Address Address Line 2 Town County Post Code

Contact number*

Child's NHS Number (if known)

Ethnic group*

We want to make sure families are able to access the services that are culturally appropriate. To help us do that, please select the box that best describes this child

Diganosis*

Please specify all medical conditions and care needs*

Approximate date of diagnosis*

Is the condition*

Life-threatening?

Life-limiting?

About the child's parents/guardians

Please provide details for the person/people who have parental responsibility

Parent/Guardian's Name*

First Last

Parent/Guardian's relationship to the child*

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

Is an interpreter required?*

Yes

No

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

Please complete this if different from child's address

Street Address Address Line 2 Town County Post Code

Parent/Guardian ethnic group

Please complete if this is different to the child's ethnic group

Would you like to add another parent/guardian?*

Yes

No

Parent/Guardian's Name*

First Last

Does this person have parental responsibility?*

Yes

No

Parent/Guardian's relationship to the child*

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

Is an interpreter required?*

Yes

No

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

Please complete this if different from child's address and different from the first parent/guardian's address

Street Address Address Line 2 Town County Post Code

Parent/Guardian ethnic group

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

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

Is the child on a Child Protection or Child in Need Plan?*

Yes

No

Please provide details*

Is there any known history of violence, drug or alcohol abuse?*

Yes

No

Please provide details*

Are there any risks for lone visiting?*

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

Parent/Guardian/carer referral

About you

Who is the support for?

About the child's parents/guardians

Other children in the household

Professionals involved with the family

Background medical information

Social Concerns

Consent