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Make a referral

If you'd like to talk to us about a child's palliative care needs - please give us a call using either of the numbers below. We'll answer all your questions and give you the support you need.

Rachel House: 01577 865 777 or Robin House: 01389 722 055

Alternatively, you can make a referral online by completing the form below.

Make a referral online

The details requested on this form are reviewed by a referral panel which helps us work out how to best help your child and family.

However, in more urgent situations, please phone us at:
Rachel House -01577 865 777 or Robin House - 01389 722 055
Ask to speak to one of the nursing or medical teams about an urgent referral. 

The information provided in the referral form below is delivered via the secure nhs.net email to ensure secure data transfer and is processed in compliance with the Data Protection Act 2018.

To help further, a knowledge of the following would be very useful:

Details of child
Do you know which service you are making a referral for?:
Family information

Please include DOB next to full name of parents and siblings where possible i.e. Jane Smith (12/05/1978).

Has the referral been discussed with the family (or with the child/young person, where appropriate)?:
Referrer details
Professional involvement

Please add the name of GP plus any other professional involved, e.g paediatrician, pharmacist, named person, lead social worker, community children's nurse / oncology outreach nurse / health visitor.

Add another
Parent/Guardian Consent

If you want to talk to someone about your own situation or find out more about our services, please get in touch: