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Self referral
Self referral form

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

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Telephone number(Required)

Mobile number

Email

NHS number (if known)

Current location

Home, Hospital etc

Date of Birth(Required)

MM slash DD slash YYYY

GP surgery(Required)

Please be aware we will need to contact the GP and relevant medical teams to gain appropriate information.

GP (if known)

Marital status

Preferred language

Next of kin details:

Name

Prefix First Last

Relationship to you

Telephone number

Address

Street Address Address Line 2 City ZIP / Postal Code

Your diagnosis

Can you give us some information on what your diagnosis is and a brief history?(Required)

What are your main concerns or issues you are finding you have currently that you would like us to help you with?(Required)

What is important to you right now?(Required)

Performance status - Please tick which box most accurately describes your current physical ability:(Required)

10: Unconscious

20: Totally bedbound

30: Almost completely bedbound

40: In bed more than 50% of time

50: Need considerable physical assistance and frequent medical care

60: Needing some physical assistance. e.g. washing & dressing.

70: Able to self care but cannot do normal work/activities

80: Normal activity with effort, some symptoms

90: Normal activity, minor symptoms

100: Normal

Current impact of illness:(Required)

Stable - You have problems and symptoms from your illness but they are adequately controlled and you feel you have an established plan on how to manage them. Your family/carer situation is stable.

Unstable - You have problems and symptoms from your illness that you do not feel are adequately managed, are getting worse or have started experiencing new symptoms/problems. Your family/carer situation is feeling unsettled.

Deteriorating - Your overall wellness is rapidly or steadily declining and you are experiencing new or worsening of your existing symptoms/problems. Your physical ability is becoming more compromised.

Dying - Death is expected within days.

Urgency - Do you feel you need to be contacted within:(Required)

24 hours

48-72 hours

1 week onwards

Is there a specific team involved in your care?(Required)

e.g condition specific consultants, district nurses, respiratory community team.

Do you have any specific requirements for how we communicate with you?(Required)

e.g an interpreter, sign language, etc?

Would you be able to travel to the hospice?

Yes

No

CAPTCHA

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.