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Children & Young People Referral Form

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Children & Young People Referral Form - Section 1 of 5
Your Name
Your Email
Triage: Please tick appropriate box

Urgent (2-4hrs) Routine (as per waiting list)
Does the patient/carer consent to this referral?

Yes No
Patient Details
Patient Name
Likes to be called
NHS Number
Gender
Date of birth
Day - Month - Year
Age
Lives with
First language
Safeguarding Concerns
Parent / Carer Details (1)
Full name
Relationship to child

Address (including postcode)

Street Address
Street Address 2
City	Region
Postal Code	Country

Contact number
Area CodePhone Number
Email
Next of kin?

Yes No
Parental responsibility?

Yes No
Parent / Carer Details (2)
Full name
Relationship to child

Address (including postcode)

Street Address
Street Address 2
City	Region
Postal Code	Country

Contact number
Area CodePhone Number
Email
Next of kin?

Yes No
Parental responsibility?

Yes No
List sibling names and dates of birth

Children & Young People Referral Form - Section 2 of 5
Patient Medical Information
Primary diagnosis of patient
Presenting condition of patient
Are there any allergies?

Yes No
Does the patient have a palliative diagnosis?

Yes No
If yes, please give more information
If yes, please give more information
Does the patient have a DNACPR in place?

Yes No
Does the patient have a ReSPECT form?

Yes No
If yes, please give more information
If yes, please give more information
Has an Advance Care Plan (ACP) been completed?

Yes No
Are anticipatory medications prescribed?

Yes No
If yes, please give more information
If yes, please give more information
Are there any communication problems?

Yes No
If yes, please give more information

Children & Young People Referral Form - Section 3 of 5
Referral Criteria
Please indicate where the patient sits in relation to vulnerability and additional factors

Respiratory Factors (low to high)

Frequent or increasing number of lower respiratory infections

PICU admission/multiple admissions, chest infections

Requirement for long term oxygen at home or long term ventilation

Tracheostomy and/or 24hr ventilation

Nutrition Factors (low to high)

Bullbar palsy affecting feeding
Aspiration severe reflux
Loss of weight
Pain/distress associated with feeding, causing progressive feed reduction

Neurology Factors (low to high)

Seizures/spasms/movement disorder requiring medication

Significant/escalating pain and distress due to muscle spasm, postural control or seizures

Episodes of status epilepticus requiring frequent hospital admissions/intensive treatment (IV infusions/PICU)

Please tick which service you would like to refer to:

Andy's Children's Service
Family Support and Spiritual Care
Please Provide Additional Information
Reason for referral
Physical/symptom management
Psychological/emotional
Religious/spritual
End of life care
Hospice @ Home
Children's Wellbeing Service
Respite
Additional information
Please give all relevant information to support this referral
Please upload any additional information to support this referral
Filename
Size
Process
Status
Add Files Start Upload

Children & Young People Referral Form - Section 4 of 5
GP & Consultant Details
GP Name
GP Practice
Contact Number
Area CodePhone Number
Email

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Named Professional (1)
Job Title
Contact Number
Area CodePhone Number
Email

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Named Professional (2)
Job Title
Contact Number
Area CodePhone Number
Email

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Consultant Name (3)
Job Title
Contact Number
Area CodePhone Number
Email

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Add more

Children & Young People Referral Form - Section 5 of 5
Initial Home Risk Assessment
How many adults/children live in the home with the patient?
Are there any pets in the home?
Are there any hazards e.g. parking difficulties/street lighting/smokers?

Yes No
Referrer Details
Fullname

First Name
Last Name

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Contact number
Area CodePhone Number
What is your professional role?
Captcha

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hello@standrewshospice.com

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Grimsby
DN32 9RP

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