Kentown Referral Copy to be added. Kentown Referral Step 1 of 5 - Consent 0% Name First Last To make this referral, you must have specific and informed consent from the service user. Please confirm you have made them aware that we will process their data as outlined in our privacy notice, and that we will share their data with our partners in order to deliver this service.Has consent been obtained for this referral?(Required) No Yes Which service(s) are you are making this referral to?(Required) Kentown Children's Palliative Care Nursing Kentown Rainbow Trust Family Support Kentown Family Service Coordination Select AllKentown Support is a community-focused model with three key complementary elements: Nursing Care, Social Care and Information and Awareness, so families can easily access all the help and support they need in their local communities. Referrer name(Required) First Last Name of person completing this form (if different from referrer) First Last Referrer email address(Required) Referrer phone number(Required)Referrer role(Required)Hospital DoctorCommunity DoctorGeneral PractitionerHospital NurseCommunity NurseSocial WorkerSchool PractitionerHospice PractitionerOccupational TherapistPhysiotherapistChaplain/Religious LeaderMidwifeOtherPlease state role Referral reason(Required) Child's name(Required) First Last Child's date of birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For antenatal referrals, input anticipated date of delivery.Mother's NHS Number If child is an antenatal referral, input mother's NHS number.Medical history/diagnosis(Required) Diagnosis group (ICD10 groupings) Cardiac Gastrointestinal Genito-urinary Metabolic Oncological Respiratory Circulatory Genetic Haematological Neurological Perinatal Undiagnosed Other Other diagnosis group Additional health needs Physical disability Wheelchair user Sensory impairment Autism Learning disability Non-verbal communication Eating disorder Other Other health needs Does the child have an Advance Care Plan (ACP)? No Yes Address(Required) Street Address Address Line 2 Town/city County Postcode Under the care of which NHS Trust is the child?Blackpool Teaching Hospitals Trust (BTHT)East Lancashire Hospital Trust (ELHT)Lancashire Teaching Hospitals Trust (LTHT)North Cumbria Integrated Care (NCIC)University Hospitals of Morecambe Bay Trust (UHMBT)Gender(Required) Female Male Other Please state gender EthnicityArabAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: OtherBlack/Black British: AfricanBlack/Black British: CaribbeanBlack/Black British: OtherMixed: White and AsianMixed: White and Black AfricanMixed: White and Black CaribbeanMixed: OtherWhite: British/English/Northern Irish/Scottish/WelshWhite: Gypsy or Irish TravellerWhite: IrishWhite: RomaWhite: OtherAny other ethnic groupNot StatedHousehold religion Preferred language Interpreter required No Yes Primary parent/carer name(Required) First Last Relationship to child(Required)ParentCarerStep-parentFoster carerLegal guardianOtherOther relationship Do they have Parental Responsibility?(Required) No Yes Email address(Required) Phone number(Required)Preferred method of contactEmailPhoneNo preferenceAdditional needs Who else lives in the family home?Please state relationship to child and ages of any childrenHas the family ever been supported by social care? No Yes Are there any safeguarding issues? No Yes Safeguarding issuesAre there any risks to lone workers visiting this family? No Yes Risks to lone workers visiting this familyAny other relevant informationCAPTCHA Δ
