Family support referral form

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.

Momentum Children’s Charity is an independent charity providing support to families. This is separate from clinical care and choosing to be referred will not affect treatment in any way.

Patient details

We ask for this information so we can understand the needs of the child and family and assess how we may be able to support. Please only include information that is necessary to support this referral.

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Ethnicity (optional. please select as appropriate)

Diagnosis(Required)

Please provide a brief overview only. Detailed medical information is not required at this stage.

Date of Diagnosis(Required)

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

POSCU/Local hospital(Required)

If you selected 'Other,' please choose from the following:

Please specify below, if your hospital is not listed:

PTC/Specialist hospital(Required)

If you selected 'Other,' please specify below:

Consultant/ Oncology nurse specialist(Required)

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

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 (Required)

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):

Confirmation Acceptance(Required)

Select exactly 2 choices.

I can confirm that I have explained Momentum’s services to the family.

I can confirm that the family is aware of this referral and that it is optional.

Confirmation that this referral is optional and that Momentum’s services have been fully explained.

Date(Required)

Referrer Signature(Required)

Referrer Name(Required)

Job Title(Required)

Referral Hospital/Organisation(Required)

If you selected 'Other,' please specify below:

Email(Required)

Contact number(Required)

Date(Required)

How we use this information

Momentum Children’s Charity will use the information in this referral to assess support needs, contact the family and provide appropriate services. Personal information will be handled securely and in confidence and only accessed by those who need it for this purpose. We may share relevant information with professionals or organisations involved in supporting the family where necessary to deliver our services, with consent where appropriate, or where required to meet our safeguarding or legal obligations. Families have rights under data protection law, including the right to access their personal information and request correction of inaccurate data. Further details can be found in our Privacy Policy: https://www.momentumcharity.org/privacy-policy/

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