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
Does this young person access another hospice?
Yes
No
Name
Given Name(s)
Surname
Gender
Male
Female
Transgender
Non-binary
Prefer not to say
Free text - Let me type
Date of Birth
-
Day
-
Month
Year
Date
Child/Young Person's NHS number
Home Address
First Line Address
Second Line Address
City
State / Province
Post Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000 000 0000.
Mobile Telephone
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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)
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Is an Emergency Care Plan/Advance Care Plan in-place?
Yes
No
Is a Symptoms Guidelines in-place?
Yes
No
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Step 3 - Religion and Ethnic Origin
Religion
Please Select
No Religion or belief
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other
Denomination
Please Select
None
7th Day Adventist
Anabaptists
Anglican
Assyrian Church of the East
Baptist
Berber
Brethren
C of E
Charismatics
Church of the Latter Day Saints
Congregationalist
Conservative
Do not wish to disclose
Eastern Orthodox Church
Evangelism
Fundamentalist
Greek Orthodox Church
Hasidic
Holiness Movement
Humanist
Jehovah's Witness
Kabbalah
Lutheran
Mahayana
Methodist
Mormon
Muslim
Nam-Daris
Nirankaris
None
Not practicing
Oriental Orthodox Church
Orthodox
Pentecostal
Pietism
Pre-Lutheran
Presbyterian
Quaker
Reconstructionist
Reformed
Restoration Movement
Roman Catholic
Shaivism
Shaktism
Shia
Smartism
Sufi
Sunni
Theravada
Unitarian
United Reformed
Vaishnavism
Vajrayana
Wahabi
Other Religion
Ethnic Group
Please Select
White: Irish
White: British
White: Gypsy or Irish Traveller
White: Other
Mixed: White and Black Caribbean
Mixed: White and Black African
Mixed: White and Asian
Mixed: Other
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Other
Black/African/Caribbean/Black British: African
Black/African/Caribbean/Black British: Caribbean
Arab
Prefer Not to Say
First Language
Please Select
English
Afrikaans
Albanian
Arabic
Arabic Languages
Aramaic
Armenian
Bosnian
Bulgarian
Cantonese
Catalan
Chinese
Cornish
Croatian
Czech
Danish
Dutch
Estonian
Filipino
Finnish
French
Georgian
German
Greek, Modern
Hawaiian
Hebrew
Hindi
Hungarian
Icelandic
Indian Languages
Indonesian
Irish
Italian
Japanese
Korean
Kurdish/Kurdî
Lingala
Macedonian
Malay
Mandarin
Maori
Mongolian
Norwegian
Pashto
Persian
Polish
Portuguese
Proto-Slavic
Romanian
Russian
Scottish Gaelic
Serbian
Serbo-Croatian
Sign Language
Sinhalese
Slovak
Spanish
Swahili
Swedish
Tamil
Thai
Turkish
Ukrainian
Urdu
Uzbek
Venetian
Vietnamese
Welsh
Other (please specify)
Interpreter Required
Yes
No
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Step 4 - Family Members
Carer 1: Relationship to young person
Carer 1 Name
First Name
Last Name
Carer 1 Email Address
example@example.com
Mobile Telephone
Living with child?
Yes
No
Please list everyone who has Parental Responsibility:
Carer 2: Relationship to young person
Carer 2 Name
First Name
Last Name
Mobile Telephone
Carer 2 Email Address
example@example.com
Living with child?
Yes
No
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Step 5 - Professional Involvement
Name of General Practitioner
Name of Hospital/Surgery
General Practitioner Telephone
General Practitioner Email
example@example.com
Name of Lead Consultant(s)
Name of Hospital/Surgery
Name of Hospital Paediatrician
Name of Hospital/Surgery
Hospital Paediatrician Telephone
Hospital Paediatrician Email
example@example.com
Name of Community Paediatrician
Name of Hospital/Surgery
Community Paediatrician Telephone
Community Paediatrician Email
example@example.com
Do you know if the Young Person has a Social Worker?
Yes
No
Don't know
Name of Social Worker
Address of Social Worker
First Line Address
Second Line Address
City
State / Province
Post Code
Social Worker Telephone
Social Worker Email
example@example.com
Please list any other professionals involved (e.g. Dietician, SALT, OT, Physio, Health Visitor, Psychologist)
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Step 6 - Referrer's Details
Date of Referral
-
Day
-
Month
Year
Date
Name
First Name
Last Name
Referrer's Phone Number
Referrer's Email Address
example@example.com
Designation
Address of Referrer
First Line Address
Second Line Address
City
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?
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Step 7 - Allergies
Please also specify the Allergy Level, e.g. Intolerance / Allergy / Life Threatening
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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:
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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
-
Day
-
Month
Year
Date
Date of Consent Given
-
Month
-
Day
Year
Date
Please let us know how you would prefer us to contact you:
Email
Post
Telephone
SMS
Name (Family)
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: