Referral form

Referral Form

Before filling in our referral form, please ensure you have read our referral criterial and information about the catchment area we support. If you need to make an urgent referral for end-of-life care, please first call Christopher’s children’s hospice directly on 01483 230960.

"*" indicates required fields

Name of Child/Young person being referred*

First Last

NHS Number*

This is a 10-digit number. Please do not include spaces. Please use mothers NHS number if this is an antenatal referral.

Gender

Male

Female

Non-binary

Date of Birth*

DD slash MM slash YYYY

Ethnicity

Home Address

Street Address Address Line 2 City County Post code

Please put the anticipated home address if the referral is antenatal.

Has the Parent/Legal Guardian agreed to this referral?*

Yes

Is the child/young person aware of this referral?

Yes

N/A

Parent / Carer One

Name

First Last

Relationship to Child*

Parental Responsibility?*

Yes

Same home address as child*

Yes

If antenatal this would be intended home address

Parent / Carer one home address

Street Address Address Line 2 City County Post code

Phone*

First Language*

Please specify first language*

Interpreter required?*

Yes

Add another parent / carer?*

Yes

Parent / Carer 2

Name*

First Last

Relationship to Child*

Parental Responsibility?*

Yes

Living with child*

Yes

Carer Two Address

Street Address Address Line 2 City County Post code

First Language*

Email*

Phone*

Siblings

Does the child have any siblings?*

Yes

Unsure

Please provide any relevant information*

Older/younger , similar condition etc?

Referral details

Reason for Referral*

Primary Diagnosis:*

Add another diagnosis

Yes

Second Diagnosis:*

Add another diagnosis

Yes

Third Diagnosis:*

Add another diagnosis

Yes

Fourth Diagnosis:*

Is this referral:*

Urgent

Routine

We class an urgent referral as one we will attempt to provide an initial response to within 4 hours.

Any known allergies?*

Yes

Allergy details:

Is there an Advance Care Plan / RESPECT document in place?

Yes

Please upload a copy of the care plan/RESPECT document if available

Max. file size: 5 MB.

Is the child / young person subject to current or previous safeguarding concerns?

Yes

Please provide further details*

Tick all that apply or have applied in the past. Hold CTRL and click to select multipe options

Please provide details of concerns:

Referrer's details

Are you the child's GP?

Yes

Select yes if you are referring on the GP’s behalf, and enter their details below.

Name*

Prefix First Last

Job Title

Name of Organisation*

Referrer Phone Number*

Referrer Email*

This can be an individual’s email or one for a relevant team.

Do you know who the child/young person's GP is?

Yes

If the GP is the referrer and their details have been given above, click no.

GP details

GP Name

Prefix First Last

GP Practice Address

Street Address Address Line 2 City County Post code

GP Phone

GP Email

Is the child/young person under the care of a Hospital Paediatrician?

Yes

If the Paediatrician is the referrer and their details have been given above, click no.

Paediatrician details

Paediatrician Name

Prefix First Last

Hospital Address

Street Address Address Line 2 City County Post code

Paediatrician Phone

Paediatrician Email

Consent

Consent*

Family has given consent

Consultant to Consultant referral

Please let us know consent details for this referral.

Consent*

Please tick to confirm the below:

The family has agreed to this referral. I understand that Shooting Star Children’s Hospices will send a consent form to the primary carer on receipt of this form.

Consent*

Please tick to confirm the below:

This is a Consultant to Consultant referral.

Referral Form

"*" indicates required fields

Name of Child/Young person being referred*

First Last

NHS Number*

This is a 10-digit number. Please do not include spaces. Please use mothers NHS number if this is an antenatal referral.

Gender

Male

Female

Non-binary

Date of Birth*

DD slash MM slash YYYY

Ethnicity

Home Address

Street Address Address Line 2 City County Post code

Please put the anticipated home address if the referral is antenatal.

Has the Parent/Legal Guardian agreed to this referral?*

Yes

Is the child/young person aware of this referral?

Yes

N/A

Parent / Carer One

Name

First Last

Relationship to Child*

Parental Responsibility?*

Yes

Same home address as child*

Yes

If antenatal this would be intended home address

Parent / Carer one home address

Street Address Address Line 2 City County Post code

Phone*

First Language*

Please specify first language*

Interpreter required?*

Yes

Add another parent / carer?*

Yes

Parent / Carer 2

Name*

First Last

Relationship to Child*

Parental Responsibility?*

Yes

Living with child*

Yes

Carer Two Address

Street Address Address Line 2 City County Post code

First Language*

Email*

Phone*

Siblings

Does the child have any siblings?*

Yes

Unsure

Please provide any relevant information*

Older/younger , similar condition etc?

Referral details

Reason for Referral*

Primary Diagnosis:*

Add another diagnosis

Yes

Second Diagnosis:*

Add another diagnosis

Yes

Third Diagnosis:*

Add another diagnosis

Yes

Fourth Diagnosis:*

Is this referral:*

Urgent

Routine

We class an urgent referral as one we will attempt to provide an initial response to within 4 hours.

Any known allergies?*

Yes

Allergy details:

Is there an Advance Care Plan / RESPECT document in place?

Yes

Please upload a copy of the care plan/RESPECT document if available

Max. file size: 5 MB.

Is the child / young person subject to current or previous safeguarding concerns?

Yes

Please provide further details*

Tick all that apply or have applied in the past. Hold CTRL and click to select multipe options

Please provide details of concerns:

Referrer's details

Are you the child's GP?

Yes

Select yes if you are referring on the GP’s behalf, and enter their details below.

Name*

Prefix First Last

Job Title

Name of Organisation*

Referrer Phone Number*

Referrer Email*

This can be an individual’s email or one for a relevant team.

Do you know who the child/young person's GP is?

Yes

If the GP is the referrer and their details have been given above, click no.

GP details

GP Name

Prefix First Last

GP Practice Address

Street Address Address Line 2 City County Post code

GP Phone

GP Email

Is the child/young person under the care of a Hospital Paediatrician?

Yes

If the Paediatrician is the referrer and their details have been given above, click no.

Paediatrician details

Paediatrician Name

Prefix First Last

Hospital Address

Street Address Address Line 2 City County Post code

Paediatrician Phone

Paediatrician Email

Consent

Consent*

Family has given consent

Consultant to Consultant referral

Please let us know consent details for this referral.

Consent*

Please tick to confirm the below:

The family has agreed to this referral. I understand that Shooting Star Children’s Hospices will send a consent form to the primary carer on receipt of this form.

Consent*

Please tick to confirm the below:

This is a Consultant to Consultant referral.