Care Referral Form

The child needs to be 0-19 on first referral, and anyone including families, can refer a child. Please complete the form online and don't worry if you don't have all of the information to hand immediately.  We can collate this at a later date. 

Alternatively you can download the referral form here and print it out and send it to us at Martin House, Grove Road, Boston Spa, LS23 6TX.


CONFIDENTIAL once completed

Step 1 - Referral Type

 

Step 2 - Child Details

Surname
 
First Name(s)
 
NHS Number
 
Date Of Birth
     
Gender
 
Home Address
 
Postcode
 
Telephone Numbers
Email
Religion
 
Ethnic Group
 
First Language
 
Nursery, School or College Attended
CCG
Is this child known to another hospice? (If yes, please state which hospice)

Step 3 - Carer's Details

Carer 1

Parental Responsibility?
Name
Relationship to child
First Language
Interpreter Required?
Address (if different to above)
Ethnic Group
Health Needs

Carer 2

Parental Responsibility?
Name
Relationship to child
First Language
Interpreter Required?
Address (if different to above)
Ethnic Group
Health Needs

Step 4 - Brothers and Sisters

  Name Male/Female DOB Health Needs
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6

Step 5 - Professional Involvement - Medical

General Practitioner (GP)
Practice Address
Telephone
Postcode
Consultant 1
Hospital Address
Telephone
Consultant 2
Hospital Address
Telephone
Consultant 3
Hospital Address
Telephone
Consultant 4
Hospital Address
Telephone
Are there any safeguarding concerns around the child or family?

Step 6 - Professional Involvement - Allied Professionals

E.g. Health Visitor, School Nurse, Children’s Community Nurse, Social Worker, Physiotherapist, Speech and Language Therapist…
  Name Title/Role Telephone
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10

Step 7 - Background Information

Nursing, Social and Medical History

Current Treatment

Child's Understanding Of Their Diagnosis And Prognosis

Details Of Regular Family Support

Other Short Breaks Or Community Support

Step 8 - Final Information

Consent


Have the child’s parents (or those with parental responsibility) consented to the referral?
 
Has the young person consented to the referral? (if applicable)
 

Referrer


Name

 
Relationship to child/job title

 
Contact Number

 
Email Address