Referrals for Specialist Palliative Care

Please use this form to refer a patient to Trinity Hospice for Specialist Palliative Care.

Referrals will be accepted for patients with a progressive, life-limiting or terminal diagnosis

Once received, this referral will be triaged by our clinical teams.

If you feel there is an urgent need for our input, please call us on 01253 952566 for advice and guidance.

Service(s) Requested

Which Trinity service(s) are you referring into?*

Please select all that apply

Community Palliative Care Team

Living Well Service

In-patient Unit

Nurse-led Clinic

If this referral is for an IPU admission, please call 01253 952592.

Consent

Is the patient aware of and consented to this referral?*

Yes

No

If no, please give details*

Permission for text message service (SMS)?*

Yes

No

Permission for virtual consltation*

Yes

No

Referrer's Details

We may need to contact you if information is missing before we accept this referral.

Name*

First Last

Job Title*

Organisation*

Daytime Telephone Number*

Email address*

Patient's Details

Patient's Name*

First Last

Patient known as

Patient's gender*

Patient's date of birth*

Patient's NHS number*

Patient's address*

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

Patient's telephone number*

Patient's email address*

Is the patient known to any other services?

Select all that apply

District Nurses

Frailty Team

Rapid Response

Community Long Term Conditions Nurse

Other

Please list any other services this patient is known to*

Carer / Next of Kin Details

Main Carer/Next of Kin Name

First Last

Relationship to Patient

Main Carer/Next of Kin telephone number

Main Carer/Next of Kin

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

Advance Care Planning

What is the patient's current GSF status?*

Red (days)

Amber (weeks)

Green (months)

Is there an EPACCS in place?*

Yes

No

Please consider putting an EPACCS in place

Risks/Safeguarding

Are there any known risks at home?*

Yes

No

Please provide more information*

Are there any safeguarding concerns?*

Yes

No

Please provide more information*

Is there a keysafe?*

Yes

No

Diagnosis and Expectations

What is the patient's life-limiting diagnosis?*

What are the reasons for this referral?*

Please include details of symptoms, psychological needs etc)

What is the patient's expectations of this referral?*

Any additional information

CAPTCHA

Referrals for Specialist Palliative Care

Please use this form to refer a patient to Trinity Hospice for Specialist Palliative Care.

Service(s) Requested

Consent

Referrer's Details

Patient's Details

Carer / Next of Kin Details

Advance Care Planning

Risks/Safeguarding

Diagnosis and Expectations

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