Referral form – Psychological support for palliative patients and/or those close to them

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Date

Email(Required)

A confirmation of receipt of this referral will be sent to you upon completion. Please provide an email address here.

Enter Email Confirm Email

Reason for referral

Are you / the person you are referring:

Living with a palliative condition
A relation to someone else living with a palliative condition
Other

Please call the Hospice on 01284 715572 to discuss this further

Details of person being referred

Name(Required)

First Last

Date of birth(Required)

Contact address(Required)

House name/number and street Address Line 2 Town County Post Code Country

Telephone number(Required)

GP practice

If other, please state:

Please do not continue with this form and instead contact the GP to find out where the patient's local hospice is.

Contact St Nicholas Hospice Care's Clinical Admin team on *** if there is a specific reason you still wish referral to be considered, e.g. moving in with a relative and changing GPs.

Is this referral for yourself?

Yes
No

Details of referrer

Name(Required)

First Last

Job title / relationship

Telephone number(Required)

Is this diagnosis for the person being referred or for a relation to that person?(Required)

Person being referred
Relation

Please give details of the diagnosis

If you are not the person wishing to be referred, is the person you are referring aware you are doing so?

I am the person wishing to be referred
Yes
No

Please do not continue without consent for referral.

Have you/the patient declined to share their records with other healthcare professionals?(Required)

Yes
No
Unknown

Why do you not wish us to share records with other healthcare professionals?

Can we leave an answerphone message on the numbers provided?(Required)

Yes
No
Unknown

If no, please tell us why

Are there any safeguarding concerns?(Required)

Yes
No

Please contact the Hospice on 01284 705252, or 01284 766133 if out of hours, to discuss.

Why is the person requesting a referral seeking support now?(Required)

Has the person requesting a referral had or is having support from mental health services?(Required)

Has the person requesting a referral had suicidal thoughts or attempts?

Yes
No
Unknown

Please provide details

Is your/their GP aware?

If these suicidal feelings are current, contact your/their GP, and/or emergency services via 999 and/or the Samaritans on 116 123 and/or First response on 0808 196 3494.

We will still process this referral but ask that you prioritise yours or their safety with immediate effect.

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St Nicholas Hospice Care will only ever use your data in relevant and meaningful ways to you.

You can learn more about data protection and change your preferences at www.stnicholashospice.org.uk/yourdata.

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Referral form – Psychological support for palliative patients and/or those close to them

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Referral form – Psychological support for palliative patients and/or those close to them

What we do:

Protecting your data

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