Referral Form | Refer a Child | Claire House Children's Hospice

Step 1 - Details of the Young Person being referred
For clarity, the term 'young person' relates to all those referred between the ages of 0-18 years.
Is this family new to the services of Claire House?*
- Yes
- No
Name*
Given Name(s) Surname
Gender*
- Male
- Female
Date of Birth*
Child/Young Person's NHS number
Home Address*
First Line Address Second Line Address City Post Code
Young Person's Email
Home Telephone*
Mobile Telephone*

Step 2 - Diagnosis
Diagnosis 1*
Please include the ICD 10 CODE if known. If not, please state N/A
Diagnosis 2*
Please include the ICD 10 CODE if known. If not, please state N/A.
Diagnosis 3*
Please include the ICD 10 CODE if known. If not, please state N/A
Full medical background and current treatment (please attach any relevant medical summaries)*
For any additional uploads please email chloe.bunting@clairehouse.org.uk
File
Max. file size: 512 MB.
Is an Emergency Care Plan/Advance Care Plan in-place?*
- Yes
- No
Is a Symptoms Guidelines in-place?*
- Yes
- No

Step 3 - Religion and Ethnic Origin
Religion*
Denomination
Other Religion*
Ethnic Group*
Other Ethnic Group*
First Language*
Interpreter Required*
- Yes
- No

Step 4 - Family Members
Carer 1: Relationship to young person*
Carer 1 Name*
Given Name(s) Surname
Carer 1 Email Address*
Mobile Telephone*
Living with child?*
- Yes
- No
Please list everyone who has Parental Responsibility:*
Carer 2: Relationship to young person
Carer 2 Name
Given Name(s) Surname
Mobile Telephone
Carer 2 Email Address
Living with child?
- Yes
- No

Step 5 - Professional Involvement
Name of General Practitioner*
Name of Hospital/Surgery*
General Practitioner Telephone*
General Practitioner Email
Name of Lead Consultant(s)*
Name of Hospital/Surgery*
Name of Hospital Paediatrician*
Name of Hospital/Surgery*
Hospital Paediatrician Telephone
Hospital Paediatrician Email
Name of Community Paediatrician
Name of Hospital/Surgery*
Community Paediatrician Telephone
Community Paediatrician Email
Do you know if the Young Person has a Social Worker?*
- Yes
- No
- Don't know
Name of Social Worker
Address of Social Worker
Street Address Address Line 2 City County Post Code
Social Worker Telephone
Social Worker Email
Please list any other professionals involved (e.g. Dietician, SALT, OT, Physio, Health Visitor, Psychologist)

Step 6 - Referrer's Details
Date of Referral
Name
First Surname
Referrer's Phone Number
Referrer's Email Address
Designation
Address of Referrer
Street Address Address Line 2 City County Post Code
Has the parent/legal guardian agreed to this referral and agreed to the sharing of medical information relating to their child?
- Yes
- No
What support would the family like from Claire House?

Step 7 - Allergies
Please also specify the Allergy Level, e.g. Intolerance / Allergy / Life Threatening
Step 8 - Current Care Package
Please provide details of day-care provision / School / Care Package:
Please provide details of current family situation:
Please provide details of current safeguarding concerns:

Step 9 - Consent Form & Sharing of Information
The family of the young person must be aware of, and consent to this referral.
Child or Young Person Name*
Date of Birth*
I give Claire House Children's Hospice permission to obtain and share personal information with other agencies to enable them to support you, your child and family.*
In order for Claire House Children's Hospice to progress your referral, we require permission to contact the health and other professionals that are involved in your child's care. How information about you will be used: Claire House Children's Hospice may request or share your personal information with other agencies and professionals including your GP, consultant paediatrician(s) & other professionals involved in the care of your child to assist us & those agencies/professionals to support your or your child & family. This could be related to all aspects of you or child's or family's wellbeing, development, safety, behaviour, physical/mental health, social care and education. It may affect the service that we offer you if you do not give us permission to share information. If you are happy for us to share personal information information above, please tick below.
- Yes
- No
Date of Consent Given
DD slash MM slash YYYY
Please let us know how you would prefer us to contact you:*
For information about service provision to your child and family: i.e. bookings, letters etc.
- Email
- Post
- Telephone
- SMS
Name (Family)*
First Surname
Date*
DD slash MM slash YYYY

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Step 1 of 8 - Young Person Details

Step 1 - Details of the Young Person being referred

Step 2 - Diagnosis

Step 3 - Religion and Ethnic Origin

Step 4 - Family Members

Step 5 - Professional Involvement

Step 6 - Referrer's Details

Step 7 - Allergies

Step 8 - Current Care Package

Step 9 - Consent Form & Sharing of Information

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