Zest Referral Form - St Elizabeth Hospice

Patient information

NHS number:*

Full name*

Preferred pronouns

He/Him
She/Her
They/Them
Other

Please enter your preferred pronouns:

Date of birth*

Address*

Brief history of diagnosis & key treatments:*

Date of diagnosis*

Current problems:

Select what this referral is for (select all that apply):*

Support with transition from children’s care and/or children's hospice care
Help with managing symptoms
Support with deterioration in patient's condition and/or changing needs
Support planning for the future
To reduce social isolation and provide opportunities for peer support
Supportive care for the whole family
Access to Zest Short Breaks or Zest Days

What are you hoping we can help with?

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) and contacting other professionals?*

Yes
No

Add further comments, if needed

GP name*

GP surgery*

GP contact phone number

Carer / next of kin details

Full name of main carer / next of kin*

Relationship to patient*

Main carer / next of kin contact phone number*

Main carer / next of kin address*

Who should be the main contact for the patient's care?

Patient
Family member
Carer

Add further comments, if needed

Accessibility & Inclusion

Is English a second language for the patient/family?

Yes
No

If the patient requires an interpreter, please specify which language:

Does the patient have additional needs related to:

Vision
Hearing
Speech
Learning disability

Please specify below as applicable:

Please detail any lone-worker concerns:

Please detail any hazards in the home or risks to be aware of:

Are there any safeguarding concerns?

Other professionals involved

Consultant(s)

District / Community Nurse

Clinical Nurse Specialist

Social Services

Community Care Funder - local authority/continuing health care

Referrer's details

Full name of referrer*

Relationship to patient*

Department

Referrer contact phone number*

Date of referral*

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