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Breathlessness referral form for professionals

Referral criteria

The patient being referred, must have a diagnosis of a life limiting illness. 

The patient or carer must be aware of this referral and aware that attendance at a clinic or group programme is for a time limited period.

Keyworker responsibilities will be maintained with the current keyworker and attendance at the clinic or group will complement your support of a patient under their current treatment programme.

This referral is for specific clinics or groups only and does not include referrals for individual appointments or complementary therapies.

Groups are often facilitated by non-clinical staff and therefore it is important that mobility, medical and care needs have been considered.

Transport  must be arranged and funded by individual patients.

A place on a group programme is not guaranteed until confirmation is given by the appropriate team leader. 


 All of these referrals will be classified as non-urgent and you can expect an initial response within 7 days.

Referrer's details

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