Is the patient aware that this referral has been made?

Yes No

Is the patient's GP aware that this referral is being made?

Yes No

Patient details:

Surname

First name

Date of birth

Address and postcode

Gender

Ethnicity

Language spoken

Marital status

Telephone number

Patient information:

Diagnosis

Date of diagnosis

Hospital number

NHS number

Location of patient

Home Hospital Other (Please state)

Does the patient live alone?

Yes No

Next of Kin/Carer details:

Surname

First name

Relationship to patient

Address and postcode

Telephone number

Referrer details:

Name

Address and postcode

Telephone number

Are you?

GP Consultant Specialist Nurse District Nurse Other (please specify)

Other services involved:

Are there any other services involved in this patient's care?

Service

GP Specialist Nurse District Nurse Other

Please give address and contact details of service

Reason for referral:

Please indicate current problems and specific aims of referral

Forms - Heading

Other relevant medical history:

Past medical history, other current illnesses, treatments, outcomes, prognosis

Nursing/Physical:

Activities of daily living, bowels, appetite, mobility, dressing, wounds, IV therapies, day-to-day nursing needs of patient

Social situation:

Housing, family, financial, community support, access to property, are there any foreseeable risks?

Emotional/psychological/spiritual insight:

Knowledge of illness/prognosis, feelings and fears, importance of religion, communication barriers for both patient and carer, ability to make decisions

Present medication:

Please list medication, dose and frequency here OR send current drug list

Which programme are you referring to?

Please choose

Dementia and Carer Support Programme Wellbeing Programme

Further information:

Does this patient have (Please only tick if the answer is yes)

Advance Care Plan uDNACPR form Key-safe in place Preferred place of care

Please state preferred place of care

Person completing referral:

Name

Date

Telephone number

Designation

Helping you

Helping us

Patient details:

Patient information:

Next of Kin/Carer details:

Referrer details:

Other services involved:

Reason for referral:

Other relevant medical history:

Nursing/Physical:

Social situation:

Emotional/psychological/spiritual insight:

Present medication:

Which programme are you referring to?

Further information:

Person completing referral:

Helping you

Helping us

Patient details:

Patient information:

Next of Kin/Carer details:

Referrer details:

Other services involved:

Reason for referral:

Other relevant medical history:

Nursing/Physical:

Social situation:

Emotional/psychological/spiritual insight:

Present medication:

Which programme are you referring to?

Further information:

Person completing referral:

Are You The Legal Age?