WELLBEING SERVICES REFERRAL

Patient Information

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Date of Birth(Required)

YYYY

Contact Information

Preferred Method of Contact(Required)

Please note, if we contact by phone we may call from a withheld number and we may leave a message if voicemail is reached.

Email Address(Required)

Phone Number(Required)

Emergency Contact Name

Prefix First Last

Emergency Contact Phone Number

Referral Information & Consent

Does the patient consent to this referral?(Required)

Yes

Is the GP aware of referral?(Required)

Yes

GP Name(Required)

Surgery(Required)

Relationship to the Patient living with a life-limiting illness(Required)

I am the patient

I am a family member, loved one/carer

I am a healthcare professional

Referrer Information

Name of Referrer

Prefix First Last

Contact Number (Referrer)

Healthcare Professional Information

Job Title (Referrer)

GP/ Surgery or Hospital (Referrer)

Consents

Consent to the sharing of data recorded at Longfield with any organisations that may care for the patient? (i.e NHS)(Required)

Yes

Consent to Longfield viewing data recorded at any other organisations that may care for the patient?(Required)

Yes

Patient Medical Information

Primary Diagnosis(Required)

Is the individual that wishes to access the services able to transport themself to Longfield?(Required)

Yes

Are there any mobility issues? (Include any walking aids)(Required)

Are there any allergies or intolerances?(Required)

Are there any concerns or any information you think we should know relating to this referral?(Required)

Wellbeing Services being referred?

Please select which services you are interested in accessing. If you are unsure, tick " I would like to find out more information."(Required)

Complementary Therapy

Creative Space

Living Well with Fatigue & Breathlessness

Move More Programme

Nordic Walking

Thai Chi Movements for Wellbeing

Mindsong Music Therapy

Relaxation Programme

Carer’s Cafe

Your Life, your Death – Advance Care Planning Group

Men’s Group

Ladies Group

Cooking For Inspiration

Being in Nature

Fork and Talk

I would like to find out more information

How did you hear about Longfield?(Required)