Family support referral form (external)

Eligibility Criteria: Momentum Children’s Charity provides Family Support to families with a child (0-18yrs) diagnosed with cancer or other life challenging condition (‘in crisis’/initial diagnosis), being cared for in one of our partner hospitals. Life-challenging is such a broad area, rather than narrow our support to specific diagnosis’ our Family Support Team will review each referral and assess whether charitable support is already available for the diagnosis and support that we can offer to the family. When a referral has been accepted, we aim to contact families within a week of referral. We reserve the right to refuse a referral if they do not meet our criteria.

Please note all referrals must be made with the consent of the family.

Patient details

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Ethnicity (optional. please select as appropriate)

Diagnosis(Required)

Date of Diagnosis(Required)

If you do not know the exact day of diagnosis please just estimate a day as close as possible.

Referral Hospital(Required)

If you selected 'Other,' please specify below:

Shared care hospital(Required)

If you selected 'Other,' please specify below:

Consultant/ Oncology nurse specialist(Required)

Family is in receipt of free school meals or pupil premium

Yes

Primary carer details

Name(Required)

First Last

Relationship to Patient(Required)

If you selected 'Other,' please specify below:

Gender(Required)

Ethnicity (optional, please select as appropriate)

Email address

Address line 1(Required)

Address line 2(Required)

City(Required)

County(Required)

Postcode(Required)

Preferred contact number(Required)

Can they communicate in English*?(Required)

If 'no' note language spoken

Other carer details. Please leave blank if N/A

Name

First Last

Relationship to Patient(Required)

If you selected 'Other,' please specify below:

Gender

Ethnicity (optional, please select as appropriate)

Address if different from primary Carer (incl. County)

Postcode

Preferred contact number

Sibling details: Please leave blank if N/A

Sibling 1 – Name

First Last

Sibling 1- Date of birth

Sibling 1- Gender

Ethnicity (optional, please select as appropriate)

Sibling 2 – Name

First Last

Sibling 2- Date of birth

Sibling 2- Gender

Ethnicity (optional, please select as appropriate)

Sibling 3 – Name

First Last

Sibling 3- Date of birth

Sibling 3- Gender

Ethnicity (optional, please select as appropriate)

Reason for referral: To offer the family the most appropriate support, please answer the following brief questions. This information will be used to monitor how our support meets the family’s needs:

Reason for referral to Momentum Children's Charity?

What impact is the patient's diagnosis having on the family?

Please give details of other organisations/support services the family is accessing so that we can work collaboratively to provide the best care for the family:

Are there any health safety or safeguarding issues that we need to consider when supporting this family** e.g. Safeguarding or safety plans, Drug/Alcohol Issues/Misuse

Declaration- I declare that the above information is accurate:

Parent/Guardian signature to confirm they agree to referral (where a signature cannot be obtained, please note that verbal consent has been gained):

Have you discussed this referral with the family?(Required)

Yes

Date(Required)

Referrer Signature(Required)

Referrer Name(Required)

Job Title(Required)

Referral Hospital/Organisation(Required)

If you selected 'Other,' please specify below:(Required)

Email(Required)

Contact number(Required)

Date(Required)

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*Why are we asking for this information? For the purposes of helping our team use the most respectful language when addressing and liaising

** All information disclosed will remain confidential and no judgements will be made. This information is being requested as staff are lone workers

Any queries please call 020 8974 5931 to speak to the Family Support Team

The information in this document is confidential and will be held in strict confidence. It will not be used for any purpose other than the evaluation of this product. No part of the document may be circulated, quoted, or reproduced for distribution outside the organisation without prior written approval from the patient/guardian.