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.

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)

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

This form cannot be submitted unless you have confirmed that you have discussed this referral with the family and explained Momentum’s service.

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)

How we use this information

Momentum Children’s Charity will use this information to contact the family, assess their needs, and provide appropriate support. We may share relevant information with professionals involved in the child or young person’s care where necessary to support them. In some circumstances, we may also need to share information to meet our safeguarding responsibilities. You can read more about how we use personal data here: https://www.momentumcharity.org/privacy-policy/

*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.

IMPORTANT: We may share relevant information with professionals involved in the child or young person’s care to ensure they receive the appropriate support. All information will be handled confidentially and shared only when necessary and in line with our privacy and data‑protection policies.