Patient details

Title

First name

Last name

Preferred contact telephone number

Alternative contact telephone number

Date of birth

NHS number

If unknown please enter ten zeros

Address line 1

Address line 2

Town

County

Postcode

Name of next of kin

What is the next of kin's relationship to you?

For example, your son

Next of kin's telephone number

Next of kin's email address

What is your preferred language?

Do you give consent for us to notify RAMA (Refugee, Asylum seeker & Migrant Action) that you need support with this referral?

Yes No

(If not applicable, please select 'no')

Please tick any vulnerabilities and specific needs

Learning disability Dementia Cognitive impairment Significant mental health Physical impairment Sensory impairment Communication difficulties

Please select all that apply

Please state e.g. deaf, blind, visually impaired, other

Deaf or hard of hearing British Sign Language (BSL) users can contact St Helena, including our Singlepoint 24/7 phone line via our website using a BSL Live button. This will connect them to a Registered BSL interpreter from the SignVideo relay service who will interpret the call.

If the patient's next of kin is deaf or hard of hearing and would benefit from this service, please indicate below

Yes, the patient's next of kin would benefit from the BSL interpreter service

What is your diagnosis?

What is your reason for referring yourself to St Helena and how do you think we can help?

What is the name of the hospital consultant or doctor leading on your care?

Have you had any contact or input from St Helena in the past?

Yes No

Which email address would you like to receive confirmation of this referral at?

Upon successful submission of this form you will receive a referral number and confirmation email. If you do not receive a referral number please call us on 01206 890 360 as your referral will not have come through to us.

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Hospice services self-referral form

Patient details

Upon successful submission of this form you will receive a referral number and confirmation email. If you do not receive a referral number please call us on 01206 890 360 as your referral will not have come through to us.

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Hospice services self-referral form

Patient details

Upon successful submission of this form you will receive a referral number and confirmation email. If you do not receive a referral number please call us on 01206 890 360 as your referral will not have come through to us.

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