Referral Form | Hospice in the Weald+

If you would prefer to make your referral over the phone or need to speak to one of our team urgently please phone 01892 820515

To explore all of our care and support on offer to adult patients approaching end-of-life as well as their loved ones and family visit Care and Support

Reason for Referral

What care and support does the person you are referring to Hospice in the Weald require?

Discover more about what we offer by visiting the Access our Care section from our menu.

Support at Home: Symptom advice, complex decision making, Advance Care Planning, as well as support with medication at home.
In-Patient Care: Symptom control that is difficult to control at home and end of life care for those in their last days.
Living Well: For those approaching last year of life. We offer a personalised programme to help people achieve what is important to them.
Occupational therapy & Physiotherapy: We support people with reduced mobility, tiredness,weakness, shortness of breath and pain - achieving realistic goals to help maintain independence.
Emotional & Spiritual Support: Talking therapies such as counselling for patients and their loved ones, to explore emotions and find peace.

Consent to Refer

If you are completing this form on behalf of a patient who is unable to provide verbal or written consent, please let us know why you are making this referral on their behalf

Details of the person you are referring

Would the patient be able to communicate via telephone or video? If not please provide details for best communication.

GP Name and Location

Clinical information

We aim to assess all patients within 14 days of referral receipt, depending on their situation.

If you are concerned that your patient requires an urgent assessment, please call a member of the team on 01892 820515.

In order to help us assess the patient’s needs and suitability to Hospice care – please provide us with copies of the following information:
- Copy of recent consultant / clinic letters
- Any recent test results
- Any recent results from diagnostic testing (MRI, X-ray, etc.)
- Any relevant blood test result

Send this information to *Hitw.hospice@nhs.net* with the person's name and Date of Birth or NHS Number as the subject line.

Risks

TO AVOID UNNECESSARY DELAY PLEASE ENSURE FORM IS FULLY COMPLETED AND ALL SUPPORTING DOCUMENTATION PROVIDED (i.e. Clinic Letters, Scan Reports, MDT Reports, Patient Summaries and any other information relevant to this referral)

I understand that by submitting this referral, Hospice in the Weald will use the information shared to contact those referred to help them access care and support where appropriate.

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Make a referral to Hospice in the Weald

If you would prefer to make your referral over the phone or need to speak to one of our team urgently please phone 01892 820515

Make a referral

Reason for Referral

What care and support does the person you are referring to Hospice in the Weald require?

Consent to Refer

Details of the person you are referring

GP Name and Location

Clinical information

Risks