FRM/HH/CC/001/02

HAVEN HOUSE REFERRAL FORM

CHILD’S DETAILS
First Name:
Surname:
D.O.B: / Male o Female o
Address:
Postcode:
Primary Carer’s Name: Relationship to Child:
Who has parental responsibility? :
Home Tel No: / Mobile No. 1:
Email: / Mobile No. 2:
CCG :
NHS Number : / ICD 10 Code:
REFERRER’S DETAILS
Name of Referrer:
Job Title:
Address:
Post Code:
Tel No : / Fax No :
Signed: / Date:
Diagnosis:
Prognosis:
Past Medical History:
Main Care Issues:
Are There Any Safeguarding or Psychosocial issues?
Is the child subject to a Child Protection Plan? If yes, please give details:
SERVICES REQUIRED (Please tick)
Care / Non Clinical
Respite Care (Day or Overnight Stays)
Neonatal Pathway for Palliative Care
End of Life Care/Butterfly Suite
Music Therapy
Symptom Management
Other: (Please State) / ¨
¨
¨
¨
¨
¨ / Pre-School Daycare
Toy Home Loan
Buddies (Sibling Support Group)
Community Play Specialist
Coffee Mornings (for Parents & Carers)
Complimentary Therapies (for Parents & Carers)
Yoga / ¨
¨
¨
¨
¨
¨
£
Have parents consented to referral?
/ Yes / ¨ / No / ¨
Is the child aware of hospice referral? / Yes / ¨ / No / ¨
Is the child known to Great Ormond Street Palliative Care Team: / Yes / ¨ / No / ¨
Is the child under the care of a Consultant at Great Ormond Street? / Yes / ¨ / No / ¨
Has a CAF (Common Assessment Framework) been completed ? / Yes / ¨ / No / ¨
Is the child currently using the services of another Hospice? / Yes / ¨ / No / ¨
FAMILY DETAILS
Mother’s Name:
Occupation:
Father’s Name:
Occupation:
SIBLINGS (Please enter all details, and tick as appropriate)
1 / Name: / DOB: / Male / o / Female / o
2 / Name: / DOB: / Male / o / Female / o
3 / Name: / DOB: / Male / o / Female / o
4 / Name: / DOB: / Male / o / Female / o
Significant Others:
Relationship to Child:
ETHNIC BACKGROUND: (Please tick as appropriate)
White / Asian/ Asian British / Black/ African/ Caribbean/ Black British
English / Welsh / Scottish /
Northern Irish / British Irish / o / Indian / o / African / o
Irish / o / Pakistani / o / Caribbean / o
Gypsy or Irish Traveller / o / Chinese / o
Other: (Please State) / Other: (Please State) / Other: (Please State)
Mixed / Other Ethnic Groups
White & Black Caribbean / o / Arab / o / Not Stated / o
White & Black African / o
White & Asian / o
Other: (Please State) / Other: (Please State)
Language Spoken:
Is an Interpreter Needed? / Yes / ¨ / No / ¨
RELIGION: (Please tick as appropriate)
Christian (including C of E, Catholic, Protestant and all other Christian denominations) / o / Jewish / o
Muslim / o
Buddhist / o / Sikh / o
Hindu / o / No religion / o
Other Religion: (Please State)
IMPORTANT
For this referral to proceed to panel, Haven House Children’s Hospice require current reports or letters from all professionals involved in the child’s care. Please include the reports or letters with the referral.
Name of Nursery/School:
Address:
Postcode: / Tel. No :
School Nurse:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
GP:
Address:
Postcode: / Tel. No: / Fax No:
Letter/Report attached: / Yes: 
Paediatrician:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Specialist Consultant:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Community Children’s Nurse:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Health Visitor:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Social Worker:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Community Paediatric Dietician:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Physiotherapist:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Occupational Therapist:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Other Professional:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Other Professional:
Address:
Postcode: / Tel. No :
Letter/Report attached: / Yes: 
Has a Continuing Care Assessment been completed? / Yes: 
No: 
In receipt of Personal Health Budget Payments? / Yes: 
No: 
In receipt of Direct Payments? / Yes: 
No: 
Does the child have a Care Package? If yes, please give details including hours, provider and whether the package is funded by health or Social Services: / Yes: 
No: 
HOURS: / PROVIDER: / FUNDED BY:

Author: Nora Rochester The White House, High Road

Implementation Date: November 2010 Woodford Green, Essex, IG8 9LB

Updated: December 2013 Telephone: 020 8506 5513

Review Date: December 2016 Fax: 020 8498 0144

Responsibility: Director of Nursing E-Mail:

Approved By: Christine Twomey Page 2 of 8 Website: www.havenhouse.org.uk