Home from Hospital Pack Referral Form

Home from Hospital Pack Referral Form

If you are finding this form difficult to fill in for any reason, you can request a paper form to be posted to you by calling 0330 2000 103.

Home from Hospital Packs are delivered between 10am and 3pm, 7 days a week, 365 days a year.

We can deliver to any location in Hertfordshire. We can deliver to the client’s home, a neighbour, or to the hospital before discharge.

Provision of personal data: we cannot provide a service without a minimum amount of personal information. These sections of the form are mandatory on this form. Please ensure that you have the client’s permission to share their data, if you are completing the form on their behalf. Please see our full privacy statement on our website link below, or give us a call on the number above.

www.hils-uk.org/privacy-policy

Before you start

You can save the form at any time and return to it later by clicking the save button at the end of each page. If you do not want to create an account, you can skip this and either copy the link to your form, or provide an email address to receive a link to your draft form.

If you have any issues completing this form, please email: hertsmeals@hils-uk.org

Eligibility
The client can receive a “Home from Hospital Pack” if they meet any one of the below criteria

1. The person has no other means of obtaining essential food items within the first 24-36 hours of being discharged?2. The person is in financial need?3. The person has no family or other means of support?
Client's details (person receiving the pack)
Name*

First NameLast Name
Address Line 1*
Address Line 2
Town*
County*
Postcode *
Telephone (main)*
Telephone (other)
Ethnicity
We are required for monitoring purposes to ask the ethnicity of all our clients to ensure the equality of our service. Please select the client’s ethnicity from the list above
Is this the address we should deliver the bag to?*

YesNo
Client Consent - please tick to confirm that:*

The client has been made aware of this referral

Delivery and Access Details
Address for delivery

Address Line 1

Address Line 2

CityCounty

Post Code
Telephone
Is there anything we need to know about delivery? e.g. is the house difficult to find?
If the client is mobile enough to collect the pack at the door, where should we leave the pack?***
***Is there a suitable place for us to leave the pack where they can access it? Is this at a suitable height that they can benddown to? Could the pack be left with a neighbour? Consider what arrangementscan be made. If you would like to discuss options with our team, please callour team on 0330 2000 103 for advice.
Please detail any safeguarding concerns you may have regarding the person or their family which our staff may need to know before going into their home:

Other services

Health & Independent Living Support (HILS) provides a “meals on wheels” service throughout Hertfordshire 7 days a week, 365 days a year. HILS also delivers a number of other services to help people remain happy, healthy, and independent in their home. If the client is interested in receiving further information about any of our other services, please tick below and our Support Team will get in touch. Please bear in mind that some of these services may have waiting lists.
Which additional services is the client interested in receiving?

Physical activity and exercise at home(free) Medication prompts / reminders (free) **** Key safe installation (£) Help from an Optician at home (free) Advocacy: help with decision making around your care and support (free) Dementia support or fun clubs (£)
****PLEASE NOTE: we can only accept requests for medication prompts from a professional who can confirm that the client has the capacity to manage, dose, and self-administer their medication.

Eligibility