Ellenor, St Ronans View, East Hill Drive

ellenor, St Ronans View, East Hill Drive,

Dartford, Kent, DA1 1AE

TEL: 01322 221315 FAX: 01322 626503

THIS FORM NEEDS TO BE COMPLETED AND RETURNED

BEFORE WE CAN ACCEPT THE REFERRAL

Referral Form

Child’s Name: ………………………………………Date of Birth………..…… M / F……......

Address: ……………………………………………………………………………………………………..

………………………………………………………………………………………......

Postcode: …………………………….

Telephone Number(s)………………………………………………:………………………………………

Ethnic Origin …………………………… First Language spoken………………………......

Religion ……………………………………………

Hospital No…………………………………NHS No: …………………………………………………...

Diagnosis…………………………………………………………………………..………………………….

…………………………………………………………………………………………………………………..

Other relevant past medical history …………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

Allergies………………………………………………………………………………………………………..

………………………………………………………………………………………......

Reason for Referral

The team support children and their families who fit into one of these four categories:

Please tick which category applies

1)Disease for which curative treatment may be feasible but may fail

(E.g. cancer, organ failure)

2) Diseases in which premature death is anticipated but intensive treatment prolong

good quality life (e.g. Cystic Fibrosis, HIV, AIDS)

3)Progressive diseases for which treatment is exclusively palliative and may extend

over many years (e.g. Battens Disease, Mucopolysaccharidoses)

4) Conditions with severe neurological disability that, although not progressive, lead

to vulnerability and complications likely to cause premature death (e.g. severe

cerebral palsy and brain damage)

Mothers name (& address if different) …………………………………………………………...

…………………………………………………………………………………………………………

Fathers name (& address if different) ……………………………………………………………

…………………………………………………………………………………………………………

Carer’s name (& address if different) …………………………………………………………….

…………………………………………………………………………………………………………

Siblings

Name(+ Surname if different) D.O.B. M/F Any medical condition affected by

…………………………………………………………………………………………......

…………………………………………………………………………………………………………………………………………………………………………………...………………………………………………………………………………………………………………………………………..

Current Treatments & Medication including dose & frequency & alternative therapies (Please attach current computer generated list if available)

…………………………………………………………………………………………………………

………………………………………………………………………………………………………...

…………………………………………………………………………………………………………

Current Symptoms:

…………………………………………………………………………………………………………

Professional Involvement

Regional Treatment Centre

Main Consultant……………………………………………………………………………………...

Hospital………………………………………………………………………………......

Telephone No: …………………………Fax No: ……………………Email: …………………….

Secondary Treatment Centre

Main Consultant……………………………………………………………………………………..

Hospital………………………………………………………………………………......

Telephone No: ………………………..Fax No: ……………………Email: ……………………..

Community Paediatrician …………………………………………………………………………..

Hospital ………………………………………………………………………………………………

Address: ……………………………………………………………………………………………..

Telephone No: ……………………….Fax No: ……………………..Email: ……………………..

GP Name……………………………………………………………………………………………..

Address: ……………………………………………………………………………………………...

…………………………………………………………………………………………………………

Telephone No: ……………………….Fax No: ……………………..Email: ……………………..

School ……………………………………………………………………………………………….

Teacher’s Name ……………………………………………………………………......

Address: ……………………………………………………………………………………………..

Telephone No: ……………………….Fax No: ……………………..Email: ……………………

Other Professionals Involved (e.g. Community Nurse, Social Worker, Physio, Health Visitor, OT)

Name: Title: Address: Tel no:

…………………………………………………………………………………………………………

Is there any Local Authority involvement with the family? (Please provide details)

…………………………………………………………………………………………………………

Current Family/Social Situation

………………………………………………………………………………………………………..

Who has parental responsibility? (Please give names & relationship)

………………………………………………………………………………………………………..

Are the patient / family aware of the referral?YES / NO

What support would the child / family like? (e.g. play therapy, counselling, respite) …………………………………………………………………………………………………………

…………………………………………………………………………………………......

Has permission been obtained to gain further information to

assess suitability of referral?YES / NO

Has GP agreed to referral?

(The agreement of the GP is essential)YES / NO

Referral made by:

Name: ………………………………………………………………….……………………………..

Position: ……………………………………………………………….……………………………..

Address: ……………………………………………………………….…………………………….

…………………………………………………………………………..……………………………..

Telephone No: ………………………………………………. Date…………………………….…

Referral taken by:

Name: ……………………………………………………………………………………………….

Position: …………………………………………………….. Date: ………………………………

CONSENT TO INFORMATION SHARING WITH OTHER PROFESSIONALS

DECLARATION:

The information I have provided is, to the best of my knowledge, accurate and up-to-date. I have read and understood the attached guidance ‘The Protection, Use and Sharing of your Information’ and I agree to the sharing of my personal information, with the following:

INITIAL

I agree to the sharing of information with other health care professionals

I agree to the sharing of information with my nominated next of kin

As required by the Data Protection Act (1998), we will ensure confidentiality and security of your information as detailed in the explanation ‘The Protection, Use and Sharing of your Information’. If you have difficulties with this form please speak to a member of ellenorclinical staff.

Completed by: (please √) Patient

Patient’s advocate/NOK

Parent/Person with parental responsibility for children under 18

Date Signed

Print Name

In the event that the patient decides to withhold consent to information sharing – this section is to be completed by the Health Care Professional in charge of the patient’s care and the patient or their representative.

INITIAL

I disagree with the sharing of my personal information

The implications of withholding consent of information sharing have been fully explained to the patient or their representative.

DateSigned

Print Name

Job Title

If, in future, your personal details change, please notify us as soon as possible.Thank you for your assistance.

THE PROTECTION AND USE OF YOUR INFORMATION

We ask you for information about yourself so that you can receive proper care and treatment.

We keep this information, together with details of your care, because it may be needed if we see you again.

We may use some of this information for other specified reasons:

THE MAIN REASONS FOR WHICH YOUR INFORMATION MAY BE NEEDED ARE FOR EXAMPLE:

Giving you health care and treatment
Sharing date with acute hospitals, GPs and ambulance services
Looking after the health of the general public. For example:
Data is submitted to support national monitoring of conditions such as cancers

Managing and planning services. For example:
Making sure that our services can meet patient’s needs in the future
Preparing statistics on performance and activity
Investigating complaints or legal claims.
Helping staff to review the care they provide to make sure it is of the highest standard
Training and educating staff (but you can choose whether or not to be involved personally)
Research approved by the Local Research Ethics Committee (if anything to do with the research would involve you personally, you will be contacted to see if you are willing to take part. You will not be identified in any published results without your agreement).
Legal requirements, sometimes the law requires us to pass on information such as to notify a death.

Everybody working for ellenorhas a legal duty to keep information about you confidential. Where services are undertaken by non-ellenorstaff, agreements are in place to ensure confidentiality. It is a criminal offence to misuse personal information and ellenor(as data controller) has taken appropriate steps to ensure there is no such misuse of the information and that the Data Protection Act 1998 is upheld.

In the event of a transfer to another health care provider, your medical records will be shared, in order to facilitate your continuing care.

You may be receiving care from other health professionals as well. So that we can all work together for your benefit we may need to share some information about you. Wherever we can we shall remove details that identify you. The sharing of some types of very sensitive personal information is strictly controlled by law. Other professionals who receive information from us are also under a legal duty to keep it confidential.

In addition to the information recorded when we first meet you, people attending to your care will request or record information about you which will form an integral part of your patient notes, and may be used as detailed above.

You have the right of access to your health records in accordance with the Data Protection Act 1998. You may request a copy of your records, subject to payment of a small fee. If you become aware of any incorrect information that we are holding about you, then you have the right to request that this information be changed or erased.

Next of Kin:

If you agree, your relatives, friends and carers will be kept up to date with the progress of your treatment. If you have to come into the Hospice at any time, the person you have designated as ‘Next of Kin’ should be the main liaison contact for this. As this person may be contacted, please ensure that they are aware that you have supplied us with their details.

If at any time you have any questions about how we use your information, you can speak to the person in charge of your care or alternatively write to: Director Of Patient Care, ellenor, Coldharbour Road, Gravesend, Kent DA11 7HQ.