Make an online referral

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

Baby's, child's or young person's full name:

DOB:

CHI:

Gender:

Male

Female

Address:

Telephone number(s):

Do you know which service you are making a referral for?:

Rachel House

Robin House

CHAS@Home

Don't know

Family information

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

Mother:

Father:

Names and DOB of any brothers or sisters:

Address:

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

Yes

Who was the discussion with?

Principal diagnosis (including date of diagnosis):

Referrer details

Name:

Position:

Address:

Contact information (phone/email):

Reason for referral for consideration of CHAS services:

Opinion of prognosis, and summary of what has been discussed with the family:

Current medical problems (including current medications):

Relevant family history:

Any other relevant information:

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.

Name:

Job title / role:

Address:

Telephone:

Email:

Add another

Parent/Guardian Consent

Yes, I confirm that verbal consent has been provided by the parent/guardian for the referral to be made and for CHAS to gather relevant medical information from other professionals and hold and share this records electronically.

Name of parent/guardian who has given consent:

What is their relationship to the child/young person?

Make a referral

Make a referral online

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