Hospice at Home Referrals | Rossendale Hospice

Rossendale Hospice Referral Form

Please complete this form as much as you can.

Service Required

You may select more than one service

Hospice at Home Wellbeing (Day Therapy) Counselling Complementary Therapy Befriending Service Early Diagnosis Day (Cancer) Dementia Diagnosis Days (new diagnosis only)

Please note children's counselling is a separate form.

Patient Information

Title

First name

Last name

Address line 1

Address line 2

Town/City

Postcode

Ethnicity

Date of birth

NHS No

Phone number

Patient's email address

May we email / text /leave a message on your answer phone or with a relative

Main Carer/Next of Kin Details

Name

Address line 1

Town/City

Postcode

Relationship to patient

Phone number

Patient's GP

GP name

Address line 1

Town/City

Postcode

Phone number

District Nurse (if applicable)

DN Name

DN Location

Phone number

Consent

Has the patient consented to this referral?

Diagnosis

Primary

Date of diagnosis

Background information

Reason for referral

Known risks to staff

ie property access, key safe, pets etc

Referrer

Referrer name

Email address

Relationship to patient

Date of referral

Telephone number

Phone number

GDPR Statement

Rossendale Hospice respects you and your data. For more details on how we securelyt store your personal information, please visit www.rossendalehopsice.org. If you would like to speak to someone about how we process your data please contact rossendale.hospice@nhs.net We will never pass your details on to any third-party for marketing purposes.

reCAPTCHA