HomeReferral formsCare referral form Care referral form "*" indicates required fields Step 1 of 6 16% Referral type Routine Urgent Symptom control End of life Community Child's detailsSurnameFirst name(s)Date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If you do not input the correct date of birth, your referral will be delayed.GenderMaleFemaleNHS numberAddress Address Line 1 Address Line 2 Town/City Postcode TelephoneMobileEmail First languageIs the child known to another hospice? (if yes, please state which hospice in the box below)YesNoName of hospice your child is known toDiagnosis Carer's detailsCarer one detailsCarer one — parental responsibility?YesNoCarer one — nameCarer one — relationship to childCarer one — first languageCarer one — interpreter requiredYesNoCarer one — address (if different to child/young person) Address Line 1 Address Line 2 Town/City Postcode Carer one — health needsCarer two detailsCarer two — parental responsibility?YesNoCarer two — nameCarer two — relationship to childCarer two — first languageCarer two — interpreter requiredYesNoCarer two — address (if different to child/young person) Address Line 1 Address Line 2 Town/City Postcode Carer two — health needs Brothers and sistersSibling one detailsSibling one — nameSibling one — genderMaleFemaleSibling one — date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sibling one — health needsDo you need to input another sibling?NoYesSibling two detailsSibling two — nameSibling two — genderMaleFemaleSibling two — date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sibling two — health needsDo you need to input another sibling?NoYesSibling three detailsSibling three — nameSibling three — genderMaleFemaleSibling three — date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sibling three — health needsDo you need to input another sibling?NoYesSibling four detailsSibling four — nameSibling four — genderMaleFemaleSibling four — date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sibling four — health needsDo you need to input another sibling?NoYesSibling five detailsSibling five — nameSibling five — genderMaleFemaleSibling five — date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sibling five — health needs Professional involvement (medical)General Practitioner (GP)ConsultantProfessional involvement (allied health professionals)Eg: Health Visitor, School Nurse, Children’s Community Nurse, Social Worker, Physiotherapist, Speech and Language Therapist, etcProfessional one detailsProfessional one — nameProfessional one — title/roleProfessional one — telephoneDo you need to add another professional?NoYesProfessional two detailsProfessional two — nameProfessional two — title/roleProfessional two — telephoneDo you need to add another professional?NoYesProfessional three detailsProfessional three — nameProfessional three — title/roleProfessional three — telephoneDo you need to add another professional?NoYesProfessional four detailsProfessional four — nameProfessional four — title/roleProfessional four — telephoneDo you need to add another professional?NoYesProfessional five detailsProfessional five — nameProfessional five — title/roleProfessional five — telephoneDo you need to add another professional?NoYesProfessional six detailsProfessional six — nameProfessional six — title/roleProfessional six — telephoneDo you need to add another professional?NoYesProfessional seven detailsProfessional seven — nameProfessional seven — title/roleProfessional seven — telephoneDo you need to add another professional?NoYesProfessional eight detailsProfessional eight — nameProfessional eight — title/roleProfessional eight — telephone Nursing, social and medical historyCurrent treatmentChild's understanding of their diagnosis and prognosisDetails of regular family supportOther short breaks or community support ConsentPlease note: If you do not complete the below, we will be unable to progress with this referral.Have the child’s parents (or those with parental responsibility) consented to the referral? Yes No Has the young person consented to the referral (if applicable) Yes No Please indicate if the parents are giving consent for us to share information with and from other clinicians on SystmOne* Yes No If you've selected no, your referral will be delayed. We use a clinical computer system, SystmOne, which lets health staff record patient information securely, onto a computer. This information can be shared with other clinicians so that everyone caring for a patient is fully informed about things like their medical history, allergies and medications. • Sharing out: This controls whether information we enter can be seen by the rest of you/your health team. An example of this is that your GP will be able to see straight away if we make any medication changes. • Sharing in: This controls whether we are able to access information which is sharable at other healthcare services. As an example, we may be able to see your last clinic letter or details of any medication changes made elsewhere. We may also be able to see when you are in hospital which is helpful and may enable us to offer support.ReferrerNameRelationship to child/job titleContact numberEmail DateDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you a professional?NoYesIs the child/young person subject to safeguarding plan?YesNoAre there any safeguarding concerns around the child or family?Martin House Criteria FormPlease indicate which group the child or young person fits into:Group one Life-limiting condition for which curative treatment may be feasible, but can fail. E.g. cancer, organ failure Patients with poor prognosis or where treatment has failed and/or during an acute crisis. NB: On reaching long-term remission or following a successful curative treatment, the child/young person will be discharged. Group two Condition where premature death is inevitable, and likely before the age of 25. E.g. Duchenne’s muscular dystrophy Group three Progressive condition without curative treatment options, likely to die before the age of 25. E.g. Battens, SMA Type 1, undiagnosed neurodegenerative condition. Group four Irreversible but non-progressive conditions causing severe disability leading to susceptibility to health complications and likelihood of death before age of 25 years. E.g. severe cerebral palsy. Group four: Please indicate most relevant point on scale that child/young person is at in relation to following vulnerability factors. (low to high)Respiratory factors Low: Frequent or increasing number of lower respiratory infections PICU admission/ multiple admissions chest infections Requirement for long term oxygen at home, or long-term ventilation High: Tracheostomy and/or 24hr ventilation Nutrition factors Low: Bulbar palsy affecting feeding Aspiration severe reflux Loss of weight High: Pain/distress associated with feeding, causing progressive feed reduction Neurology Factors Low: Seizures/spasms/ movement disorder requiring medication Significant/escalating pain and distress due to muscle spasm, postural control or seizures High: Episodes of status epilepticus requiring frequent hospital admissions/intensive treatment (IV infusions/PICU) Other relevant factors that demonstrate vulnerability (such as pain, distress, social factors, etc)
