Professional Referrals - St Elizabeth Hospice

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Professional Referral Form – East Suffolk

This form is for professionals to refer to St Elizabeth Hospice services in Ipswich & East Suffolk.

Step 1 of 9

11%

Referrer's Details

Referrer's name:(Required)

First Last

Job title:(Required)

Telephone number:(Required)

Email address:(Required)

Enter Email Confirm Email

Patient Details

Patient name:(Required)

First Last

Preferred name:

Date of birth:(Required)

DD slash MM slash YYYY

NHS Number:(Required)

Address:(Required)

Street Address Address Line 2 City Postcode

Telephone number:(Required)

Patient's first spoken language:(Required)

Is an interpreter required?(Required)

Yes

No

Patient's current location(Required)

Next of Kin Details

Do you have next of kin details?(Required)

Yes

No

Full name:(Required)

First Last

Relationship to patient:(Required)

Is the address the same as the patient?(Required)

Yes

No

Don’t know

Address:(Required)

Street Address Address Line 2 City Postcode

Is the telephone number the same as the patient?(Required)

Yes

No

Don’t know

Telephone number:(Required)

Consent

Has the patient consented to this referral?(Required)

Yes

No

Please give details as to why the patient has not consented:(Required)

Is the family aware of the referral?(Required)

Yes

No

Please provide details about why the family are not aware:(Required)

Please advise of any request/preference of who to contact regarding referral:

Please give a reason why (where appropriate patient must consent to this):

Medical

Primary diagnosis for the referral:(Required)

Other significant medical conditions:(Required)

What are the current unmet needs are you hoping we can help with?(Required)

Pain

Breathlessness

Nausea / vomiting

Anxiety

Emotional distress

Spiritual distress

Care in the last days of life

Carers needs

Other

Please specify:(Required)

If you are wanting to refer to a particular service of the hospice, please select one of the below:(Required)

Inpatient Unit

Community Team

Not specified/unsure

Interventions already taken to address needs, including medications:

What follow up plans do you have for the patient?(Required)

Other Services Involved

Please select which other community teams the patient is known to:(Required)

District Nurse

Respiratory Team

Community Matron

Nurse Specialist

Integrated Neighbourhood Team Therapy Services

CHC

Social Services

None/not known

Please state which team:(Required)

Advance Care Planning

Has a ReSPECT form been completed?(Required)

Yes

No

Unsure

CPR status(Required)

For Resuscitation

Do Not Resuscitate

Unsure

Details of any other advanced care planning information:

Vulnerabilities & Specific Needs

Please select whichever apply:(Required)

Learning disability

Dementia

Cognitive impairment

Significant mental health diagnoses

Physical/functional impairment/ability

Sensory impairment

Communication needs

No vulnerabilities

Please give more detail if needed:

Are reasonable adjustments required?(Required)

Yes

No

Please detail what reasonable adjustments should be made:

Hazards

Please detail any known safeguarding risks:

Please detail any known lone worker concerns:

Please detail any known hazards in the home or infection risks:

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