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Complementary Therapy Referrals

Rossendale Hospice Referral Form

Please complete this form as completely as you can.

Service Required

Please note children's counselling is a separate form.

Patient Information

Main Carer/Next of Kin Details

Patient's GP

District Nurse (if applicable)

Consent

Diagnosis

ie property access, key safe, pets etc

Referrer

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.