Self referral

We welcome self-referrals for adults with a life-limiting condition, living in our catchment area (see below). Our aim is to make it as simple as possible to self-refer and this can be done by an individual, their family, carer or loved one.

Self referral

Personal details

Home, Hospital etc
MM slash DD slash YYYY
Please be aware we will need to contact the GP and relevant medical teams to gain appropriate information.

Next of kin details:


Your diagnosis

Performance status - Please tick which box most accurately describes your current physical ability:(Required)
Current impact of illness:(Required)
Urgency - Do you feel you need to be contacted within:(Required)
e.g condition specific consultants, district nurses, respiratory community team.
e.g an interpreter, sign language, etc?
Would you be able to travel to the hospice?

What happens to your referral:

We will contact your GP surgery to inform the GP of the referral and to request medical information. We share electronic records with other healthcare professionals and will liaise with appropriate teams to ensure we have all the relevant information.

Depending on the urgency of your referral we will contact you within the relevant time frame to discuss your referral and if appropriate to accept we will allocate you an initial assessment with the relevant team.

Out of hours referrals – if you need to make an urgent referral out of office hours then contact us directly on nurseline at 01323 434222.

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