Referral "*" indicates required fields Type of referral Routine Emergency Bereavement Consent* I can confirm that the parent has agreed to the referral and to Helen & Douglas House processing their child’s information.View our privacy policy. If this is an emergency, end-of-life care referral please call us on 01865 796771 . Your Details Relationship to the child being referred*ParentCarerSiblingNurseConsultantSocial workerMedical ProfessionalOtherName* First Last Email* Phone*Are the family aware of this referral?* Yes, I have consent from the family to make this referral. Referral Details Which of our services are you interested in? Supportive Stays Symptom / Medication Review Outreach End of Life Care Which of our family support services are you interested in? Family Support Social Work Sibling Support (Including Bereavement) Transition / Youth Work Bereavement Services Use of Little Room Bereavement Support Family member details*If the chosen service is for another member of the family, please include name, contact details (including NHS no and/or date of birth) and their relationship to childHas the child been referred to or is currently using another hospice?* Yes No Please give more details*Are you aware if the child is on a Child Protection Plan? * Yes No Please give more details*Are you aware of any safeguarding concerns?* Yes No Please give more details*Are there any reasons why a home visit by a lone worker should not be undertaken?* Yes No Please give more details* Child’s Details Young Person Name* First Last Date of Birth* DD slash MM slash YYYY NHS Number (If Available)Sex*EthnicityAsian or Asian British: IndianAsian or Asian British: PakistaniAsian or Asian British: BangladeshiAsian or Asian British: ChineseAsian or Asian British: Any other Asian backgroundBlack, Black British, Caribbean or African: CaribbeanBlack, Black British, Caribbean or African: AfricanBlack, Black British, Caribbean or African: Any other Black, Black British, or Caribbean backgroundMixed or multiple ethnic groups: White and Black CaribbeanMixed or multiple ethnic groups: White and Black AfricanMixed or multiple ethnic groups: White and AsianMixed or multiple ethnic groups: Any other Mixed or multiple ethnic backgroundWhite: English, Welsh, Scottish, Northern Irish or BritishWhite: IrishWhite: Gypsy or Irish TravellerWhite: RomaWhite: Any other White backgroundOther ethnic group: ArabOther ethnic group: Any other ethnic groupChild's DiagnosisPlease provide primary diagnoses and other relevant medical informationPrevious Medical History*Are there any psychosocial issues we should be made aware of?Please include key problems, social considerations and also indicate any particular expectations of the child or familyThis person is being referred to a service at Helen & Douglas House because*This person is being referred to a service at Helen & Douglas House because File UploadMax. file size: 64 MB. Family Details Parent Details*Please provide name and contact detailsParental responsibility held by:*Ethnicity*First language of main contact*Will any translation services be required, if so please provide detailsHome Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Main Contact Phone Number*Alternative Contact Phone NumberSiblingsPlease provide name and DOB for siblings Professional Involvement GP Name* First Last Practice, Address & Contact details*Consultant Name* First Last Practice, Address & Contact details*It is assumed by sending in this form that you have granted us permission to directly contact your healthcare professionals Your Details Your Name* First Last Your Email* Services Required* Parent Bereavement Support Sibling Bereavement Support Parent / child aware of referral? Yes No Parent / child consented to referral & info sharing agreement? Yes No Are they already known to Helen & Douglas House? Yes No Details of the Person Being Referred Name* First Last Date of Birth* DD slash MM slash YYYY NHS NumberHome Address Street Address Address Line 2 City County Post code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Child’s details Please provide some details about the child who has diedName First Last Date of Birth* DD slash MM slash YYYY Date of death* DD slash MM slash YYYY NHS NumberMedical Certificate of Cause of Death (MCCD) able to be written? Yes No Coroners' referral?* Yes No GP Name* First Last GP Contact DetailsKey Worker Name First Last Key Worker Contact DetailsWho had parental responsibility?Diagnosis of child*Clinical Situation leading up to referral*Contact details for other professionals and agencies involvede.g. neonatal bereavement nurse, or bereavement midwife.As a team, we often lone work. Are there any known risk factors for this child/family that you are aware of? Yes No Please provide details*
