Accessibility tools

Accessibility tools

OneCall 24/7 specialist advice line
Call Fundraising
Call Main Office
Log In
Basket (0)

St Elizabeth Hospice

Donate

How we can help
Zest
- What is Zest?
- How you can support
  - Shop
  - Volunteer
  - Donate
  - Fundraise
- 24hr Advice0800 567 0111calls are free from a BT landline.
About us
- About us
- News
- 24hr Advice0800 567 0111calls are free from a BT landline.
Support us
- Support Us
- Events
- Donate
- 24hr Advice0800 567 0111calls are free from a BT landline.

menu

Ipswich & East Suffolk referral form

St Elizabeth Hospice
- How can St Elizabeth Hospice help you?
Information and Support
Hospice Care

Home
How we can help
Information and Support
Referral form
Ipswich & East Suffolk referral form

Please complete this form with as much information as possible. Not all fields will be relevant to the referral.

Asterisks (*) indicate a mandatory field.

Patient information
NHS number:*
Full name*
First
Preferred pronouns
- He/Him
- She/Her
- They/Them
- Other
Please enter your preferred pronouns:
Date of birth*
DD slash MM slash YYYY
Address*
GP name*
GP surgery*
GP contact phone number
Is the patient home?*
- Yes
- No
Patient contact phone number*
Other location (including hospital/ward)
If other location is specified, contact phone number at patient's location
Is the patient aware of their diagnosis and/or prognosis?*
- Yes
- No
Is the patient aware and has agreed to referral?*
- Yes
- No
Is this a referral in patient's best interests due to lack of capacity?*
- Yes
- No
Family aware of and agree to referral?*
- Yes
- No
Has patient consented to sharing of information (EDSM)?*
- Yes
- No
Carer / next of kin details
Full name of main carer / next of kin*
First
Relationship to patient*
Main carer / next of kin contact phone number*
Main carer / next of kin address*
If the patient requires an interpreter, please specify language
Accessible information standards
Does the service user have additional needs related to:
- Vision
- Hearing
- Speech
Please specify below as applicable:
Is this referral for:*
- Community assessment and support
- Community Care Unit, Ipswich
- Hospice Inpatient Unit, Ipswich
What are you hoping we can help with?
Brief history of diagnosis and key treatments*
Date of diagnosis
DD slash MM slash YYYY
Reason(s) for referral?*
- Pain management
- Symptom management
- Emotional / psychological support
- Social / financial
- Spiritual
- Carer's needs
- Palliative rehabilitation needs
- Other
If other, please specify reason(s)
Current problem(s)
- Pain
- Vomiting / nausea
- Anorexia
- Breathlessness
- Psychological
- Constipation
- Diarrhoea
- Anxiety
- Depression
- Mobility
- Communication
- Social
- Confusion
- Other
If other, please specify problem(s)
Mobility issues
Equipment needs
Lone-worker concerns
Any hazards in the home or risks to be aware of
Advance care planning
Does the patient have an advance care plan document: If yes, then which one(s)?
- Preferred place of care
- Preferred place of death
- Treatment escalation plan
- ReSPECT form
- CPR status
- Advance decision to refuse treatment
- Don't know
- Other
If the patient has a preferred place of care or death, please specify where
Is the patient on the Gold Standards Framework Register?
- Yes
- No
If yes, please specify
Other professionals involved
Consultant(s)
District / Community Nurse
Clinical Nurse Specialist
Social Services
Referrer's details
Full name of referrer*
Relationship to patient*
Department
Referrer contact phone number*
Date of referral*
DD slash MM slash YYYY
CAPTCHA

Sign up to receive monthly updates

Here when you need us

Terms and Conditions
Privacy Policy
Cookies
Sitemap
Contact

© Copyright St Elizabeth Hospice (Suffolk) 2023

A company limited by guarantee and not having a share capital Registered Charity No. 289154

Website by Itineris

Share your story