Little girl sat on a bench in the hospice garden.

Make a referral

If you'd like to refer a child or family to us, even in pregnancy, we make the process as fast and simple as possible:

Why not make your life easier, and a family's life better?

Please note - fields marked with an * are mandatory.

1. About you

Please enter your details (the individual filling in the form)

2. What support do you/this family need?

3. Who is the support for?

Please provide details about who needs our support.
Select a choice

Gender


Ethnic group

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

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4. Parent/guardian details

Please complete if you're referring a baby or child. 



Parent/guardian #1:
Parental responsibility?

Interpreter required?



Parent/guardian #2:
Parental responsibility?

Interpreter required?

5. Other children in the family

Please give details of any other children in the family you are referring. Please fill in the name, date of birth, gender and healthcare for each child. 

6. Professionals involved with the family- eg social care, GP, consultant, health visitor, CCN, education etc

Does the person being referred (or those with parental consent) consent for us to contact the professionals listed below in order to gain accurate information?*

7. Background information

8. Known risks

To help us make an informed decision, are there any known risks within the family’s home environment: Please tick appropriate box:*


9. Consent

Has the person being referred (or those with parental responsibility) consented to the referral?*

Has the patient / parent / relative consented to the sharing of their electronic patient record?

Forget Me Not Children’s Hospice will use the information provided on this form in order to process the referral, and determine how best we can support the child and family. Information will also be used to ensure we are providing the safest and most effective treatment for the child and family. Information will be securely held on our systems, and only held for as long as we have a legitimate reason. For full details on how this information will be used, please visit our website (https://www.forgetmenotchild.co.uk/clinical-privacy) to view a copy of our Privacy Policy. You can also contact us on 01484 411040, or write to us using the address at the bottom of the page.