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Getting help

If you live in West Yorkshire and your child or family need our help, please get in touch

With you, every step of the way

If you’d like to know more about what we do, or if you want to visit or just talk to someone, please call or email us. You‘re not alone. We’re here for your child, and for you and your whole family. And we’ll guide you through every step to get the care and help you need.

Call us on 01484 411042 or email care@forgetmenotchild.co.uk.

You can also refer your child and family to us by completing the form below. Your GP, social worker or other health or social care professional can also refer your child or family to us, with your permission.

Make a referral

Often referrals are made by consultants, GPs, care professionals, social workers and so on, but you can refer yourself or your child to us directly too. Simply complete this form to help us get a better understanding of your situation. This will help us make sure you get exactly the right support for you.

"*" indicates required fields

1. About you

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

2. Consent

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 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.
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?*
For example: advice, a break, counselling, bereavement support, support during pregnancy and birth, care at the end of a child’s life.
4. Who is the support for?*
Please provide details about who needs our support.
Name
DD slash MM slash YYYY
Gender
If known.
We want to make sure families are able to access services that are culturally appropriate. To help us do that, please tell us the ethnicity that best describes your family, e.g. Asian British, White British.

5. Parent/guardian details

Please complete if you’re referring a baby or child.
Name of parent/guardian #1
Parental responsibility
DD slash MM slash YYYY
Interpreter required?
If different from above.
If different from above.
Name of parent/guardian #2
Parental responsibility
DD slash MM slash YYYY
Interpreter required?
If different from above.
If different from above.

6. 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.
Name, DOB, gender, healthcare needs
Name, DOB, gender, healthcare needs
Name, DOB, gender, healthcare needs
Name, DOB, gender, healthcare needs
If you have more than 4 children, please fill in the names, date of birth, genders and healthcare information below

7. Professionals involved with the family

eg social care, GP, consultant, health visitor, CCN, education etc
Consent to contact?*
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?
Practice address
Please provide details of any other professionals involved with the family e.g. social worker, mental health worker – and provide their name and contact email/phone number.
Please provide more details about why you’re making this referral e.g. medical history, if the family are bereaved, any relevant dates or incidents.
Please give details of any wider concerns affecting the family e.g. housing, employment, finances, education, mental health and wellbeing, disability, if any.
Is there a history of violence or substance abuse in the family home?*
Please tick appropriate box.
How did you hear about us?
Please type your name in full.
DD slash MM slash YYYY

Your questions answered

If you live in West Yorkshire and your baby or child has a life-shortening condition (and is under 19 years of age) or your baby or child has died within the last two years, you can be referred to us. You might be referred by your GP or a nurse, social worker or hospital consultant. Or you can refer yourself by completing the form opposite.