Child - Referral - Keech Hospice

Refer a child / young adult

Does the child/young adult have a life-limiting, life-threatening condition(Required)

Yes

No

Does the child / young adult have a life-limiting, life-threatening condition?

Child/Young Adults details

Please add details of the child / young adult (under 18) being referred:

Name(Required)

First name Surname

Date of Birth(Required)

NHS number (if known)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GP Details

GP Name / Name of Surgey/Practice(Required)

GP Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your details

Name

First name Surname

Relationship to child/young person(Required)

Your Address (if different from the child/young person)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Enter Email Confirm Email

Are you happy for us to contact you by telephone?(Required)

Yes

No

Are you happy for us to leave a message/voicemail?(Required)

Yes

No

Are you happy for us to contact you by email?(Required)

Yes

No

Please confirm the best time of day to contact you(Required)

Lead Medical Professional

To support your referral it may be helpful for us to contact the lead medical professional overseeing their care.

Job title (e.g. Consultant, paediatrician, GP etc.)

Full name

Hospital, GP Surgery, organisation or NHS Trust) (if known)

Telephone (if known)

Email (if known)

In a few short words, please tell us briefly about the child’s diagnosis and the reason for your enquiry(Required)

Are you happy for us to contact the child/young adult’s GP for additional information to assist with processing your referral?(Required)

If no, please be aware additional information will be required from your GP to proceed with your self-referral. In the absence of the authority to contact your GP, we may be unable to proceed with your referral.

Yes

No

Thank you for completing your Keech Hospice self-referral. Our team will be in touch within 48 hours to process your enquiry. If your enquiry is urgent or you’d like to speak directly with a member of our care team, please call our CIPU team on 01582 497871 or email keech.child.referral@nhs.net.

The information provided by yourself and your GP will be held securely and confidentially in accordance with the principles of General Data Protection Regulation 2018. As part of our data protection policy, Keech Hospice will only use your personal data for the purpose of your enquiry.

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Refer a child to Keech

Refer a child / young adult

Child/Young Adults details

GP Details

Your details

Lead Medical Professional