Children's Counselling Referrals

Rossendale Hospice Referral Form - Child or Young Person

This form should be used for referrals for a child or young person and include guardian details. Please complete this form as completely as you can.

Service Required

You may select more than one option

Pre-Bereavement Counselling Bereavement Counselling Anxiety re the health of a relative Young carer

Child or Young Person's Information

Gender Identity

First name

Last name

Address line 1

Address line 2

Town/City

Postcode

Date of birth

NHS No

Patient's telephone number

Patient's email address

May we email / text /leave a message on your answer phone or with a relative

Next of Kin / Parent / Guardian Details

Name

Address line 1

Town/City

Postcode

Relationship to young person

Telephone number

Email address

May we email / text /leave a message on your answer phone or with a relative:

School / College Attended

Place of education

Named contact there

Position

Telephone no.

Child's / Young person's GP

GP name

Address line 1

Town/City

Postcode

Telephone number

Any known risks to staff or young person

Consent

Has the patient consented to this referral?

Reason for referral

Background information

Referrer name

Relationship to young person

Telephone number

Date of referral

GDPR Statement

Rossendale Hospice respects you and your data. For more details on how we securelyt store your personal information, please visit www.rossendalehopsice.org. If you would like to speak to someone about how we process your data please contact rossendale.hospice@nhs.net We will never pass your details on to any third-party for marketing purposes.

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