Specialist Palliative Care Referral Form

Please provide as much information as possible to support this referral for example uploading recent letters, scan reports etc.

*Spam Guard: What is 13 + 7?

REFERRAL CRITERIA
All of below:
- Patient has progressive, life limiting diagnosis.
- There is complex symptom control, complex functional or psychological issues important to the patient, that cannot be readily managed by the team responsible for care.
- The patient agrees to referral to the Community SPC Team, if competent to choose.
If the patient is felt to be in the last four weeks of life, without complex needs, then they will require Hospice @ Home support.

If Hospice @ Home referral is URGENT, please telephone referral TEL: 03000 271 284

Incomplete forms cannot be accepted; we may need to contact the referrer for additional information

*Referral for:

Section 1 - Referrer's Information

*Legal First name

*Legal Last Name

*Referrers Role / Position

*Referring Hospital / Organisation

*Telephone

*Mobile

*Email

Section 2 - Key information about the Patient

*Does the patient consent to referral

*Legal First Name

*Legal Last Name

*Address and post code

*Home telephone number

*Mobile number

*Date of birth

*Age

*Gender

Marital status

Ethnicity

Religion

*NHS number

*GP surgery

Hospital number

*Language spoken

*Next of Kin name

Next of kin address and post code

*Next of kin telephone number

Mobile number

Other significant relationships - include name, relationship and contact number

*Are there any access or lone worker concerns? If yes, please provide details for example staff safety within the patient's home

*Patient current location

*Diagnosis

*Recent treatments

Co-morbidities

*Is this referral for yourself?

	Yes	No	Unknown
*Is Patient aware of prognosis?
*Are the patient's family/carers aware of prognosis?
*Has a ReSPECT form been completed?
*Have CPR recommendations been completed on the ReSPECT form?
*Has patient been referred to DN Team for Generalist Palliative support?
*Have anticipatory medicines been prescribed?
*Are they in the house?
*Is CHC funding in place?
*Is care package in place?

	Yes	No	Unknown
*Has a Special Patient Note (SPN) been completed?
*Has SPN been shared with northants111@nhs.net?
*Has SPN been shared with Marie Curie Rapid Response (last 8 weeks of life) via lat.mariecurie-northants-eol@nhs.net?
*Has there been a referral to Marie Curie night sits?

NHFT Referral Forms

SPC Palliative Care Referral Form

Please select from the following before proceeding

Section 1 - Referrer's Information

Section 2 - Key information about the Patient

Referral information

Attachments

Thank you for submitting a referral. Your response has been recorded.