• Referral Form

  • Is this referral for:
  • If you would like to refer a child or young person for urgent symptom management, end of life care, or care after death, please call Hope House (Oswestry) 01691 671 999 or Ty Gobaith (Conwy) 01492 651 900 to discuss the referral.

  • Preferred hospice site
  • Is this a:
  • Type of professional
  • Type of self referral
  • Basic information

  • Has this child/young person been previously referred to our services
  • Does the child/young person currently access another children's hospice?
  • Child/Young person's DOB*
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  • Additional information

  • Is an interpreter required to proceed with this referral?
  • Medical information

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  • Additional medical information

  • Does the child/young person have an Advance Care Plan in place?
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  • Does the child/young person have a symptom management plan
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  • Nursing requirements (please select all that are relevant)
  • Details of Parent/Carer 1

  • Does Parent/Carer 1 have parental responsibility?*
  • Will Parent/Carer 1 have parental responsibility?*
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  • Is parent/carer 1 living with the child/young person*
  • Details of Parent/Carer 2

  • Does Parent/Carer 2 have parental responsibility?
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  • Is parent/carer 2 living with the child/young person
  • Professional Involvement

  • Safeguarding

  • Are there any known safeguarding concerns relating to the child/young person being referred, and/or any other member of the household?*
  • Are there any known concerns relating to lone working?*
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  • Consent

  • At Hope House and Ty Gobaith we aim to work with you, as part of a multi-agency team, to provide the best care and support for your child/children and to you and your family. To do this effectively it is helpful for those caring for your child/children to be able to share information with each other.

    Parents/Carers: At Hope House/Ty Gobaith, we will share information with those who have parental responsibility for the child/young person. Please note that we are not usually able to withhold information from an individual who has parental responsibility unless there is a Court Order in place which limits their rights to request/receive information.

    Extended family members: We will not share information with extended family members/family friends unless we have the explicit permission to do so from a person with parental responsibility (e.g. if a grandparent contacts the hospice for an update regarding a child/young person, we will not be able to provide this unless we have recorded the explicit permission of those with parental responsibility for that individual)

    Professionals: With your consent, we would like to be able to request information from other professionals to assist us to care for your child and meet their needs (this would include requesting specialist care plans, or requesting updates about other professionals’ plans/involvement). We would also like to be able to share information, with your consent, with other professionals involved in your child(ren)’s care, to ensure consistency and improve the care and support that we offer to your child/family. This would include updating other professionals regarding your child’s stay at the hospice, or any information shared with us by you which relates to their care needs.

    * In cases where there are concerns for the safety of an individual, this will take priority and information may be shared without your consent, in the best interests of the individual.

    Where possible, you will be informed that we need to do this however, in some circumstances, your consent would not be required, as we have a duty to share information for the purposes of safeguarding, in line with National Safeguarding Procedures, Legislation and our Safeguarding Policy.

    For further information, please refer to the following: https://www.hopehouse.org.uk/safeguarding

    To understand how Hope House use and secure information and your rights concerning the personal information that we hold for you, please review our privacy policy at: https://www.hopehouse.org.uk/privacy-policy.

  • In making this referral I confirm that:

  • Referrer details

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  • Should be Empty: