Self referral form for emotional & spiritual wellbeing support

If you are filling in this form on behalf of someone else, please fill in their personal details rather than yours.

Once you click submit, the team will be in touch.

If you have any issues, please call the team on: 0300 303 5196, Monday - Sunday, 9am-4pm.

Are you referring yourself or on behalf of someone?*
If you are referring someone else, please detail your relationship to the patient
Full name*
Preferred pronouns
- He/Him
- She/Her
- They/Them
- Other
Please enter your preferred pronouns:
Date of birth*
Month
Day
Year
Address Line 1*
Address Line 2
City/Town*
County*
Postcode*
Phone number (home)
Phone number (mobile)
Email address
Preferred method of written contact*
- Post
- Email
Preferred contact number*
- Home
- Mobile
Ethnicity*
Gender*
Primary Language*
Religion
Do you consider yourself to have a disability?*
If yes, please tell us if you require any access support
Reason for referral*
Detail issues or concerns that have prompted this referral
Detail who is in the family unit
Are you known to St Elizabeth Hospice already?*
Are there any other health professionals/agencies involved in your support?*
For example, mental health services
If yes, please give details including name/address/telephone numbers of support services you use
For example, mental health service. If so, please give details e.g. name, address, telephone numbers
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