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Referral to St Raphael's Hospice

To make a referral please complete the online form below or download the Pan-London All Age Specialist Palliative Care Referral Form V4 – Outpatient, Community and Hospice Services  and email to srh.referrals@nhs.net

This field is for validation purposes and should be left unchanged.

THIS REFERRAL FORM IS FOR USE BY HEALTHCARE PROFESSIONALS ONLY.

If you wish to be referred or have a friend or family member who requires our support please reach out to their GP or any healthcare service they are in contact with

Referral Form to St Raphael's Hospice

This referral form follows the pan-london all age specialist palliative care referral form. If the referral is urgent requiring assessment within 48 hours, please call us to discuss
Is the referral Urgent? (if urgent please call us on 0208 099 7777)(Required)

About the Referrer

Your Details(Required)

How Can We Reach You?

We would love to chat with you. How can we get in touch?
Your Email Address(Required)

Essential Patient Details

Name(Required)
MM slash DD slash YYYY
Address(Required)
Risks for visiting(Required)
If yes give details below
Any access issues (e.g key safe)(Required)
if yes give details below
Fluent in English(Required)
If english is not first Language please provide below
Is an interpreter needed(Required)
If yes please state language/type of interpreter required below

Consent

Has the patient Consented to this referral(Required)
If Patient lacked capacity to consent to referral, who consented?
Has Patient been told diagnosis(Required)
Does the patient discuss the illness freely?(Required)
Is the patient an adult at risk of abuse or neglect?(Required)
Is there an ongoing safeguarding investigation?(Required)
Is a Deprivation of Liberty Safeguard in place?(Required)

Important Contacts

Key contact / Next of Kin Name(Required)
Do they live with the patient?(Required)
Address(Required)
Does the patient representative hold a LPA for health and wellbeing(Required)
Is the patient representative the first point of contact?(Required)
Are they aware of the patient's diagnosis?(Required)
Does the representative discuss the illness freely (if applicable)?(Required)

2nd Key Contact / Next of Kin

Name
Does the patient representative hold a LPA for health and wellbeing
Are they aware of the patient's diagnosis?
Does the representative discuss the illness freely (if applicable)?

General Practitioner

Address
Is the GP aware of the referral? (if no please inform the GP)(Required)
Will you be emailing the discharge/GP Summary?(Required)

Clinical Information

Prognosis(Required)
Service requested(Required)
Please specify reason for admission. (please email the Admission score sheet to srh.information@nhs.net)(Required)
Reason(s) for referral(Required)
Services patient is already known to or referred to:(Required)

Care Planning

DNACPR in place?(Required)
Does the patient have a universal care plan(Required)
Other advance care planning information (preferred place of care / death/ treatment escalation plan / advance decision to refuse treatment etc.)?(Required)
Any communicable infection e.g. Clostridium difficile / MRSA / flu etc.?(Required)
If yes, does patient need barrier nursing?(Required)

Special device(s) and equipment

Does the patient have a special device in situ?(Required)
Does the patient need special equipment (e.g. bariatric, ventilation equipment or complex manual handling))(Required)

Other past relevant medical and psychiatric history

Medication(s)

Has the patient got anticipatory subcut medication(s)?(Required)
Known drug sensitivities/allergies(Required)

Patient wishes and spiritual needs

Current location of patient

Location of patient(Required)

For patients in hospital

MM slash DD slash YYYY
Is palliative care team involved?