Referral Form

Consent is required by the family before making this referral to confirm family is aware that their data will be shared across the Kentown Support Service and that they may be contacted by a member of the Kentown Team (nurses, family support workers, service coordinators or counsellors) .

Has consent been obtained for this referral?

Yes

No

Support Required

Family Service Coordinator

Family Support Worker

Therapeutic Counselling (Greater Manchester)

Nursing

Tick if this is an URGENT referral for END of LIFE CARE

Which Programme?

PROGRAMME 1- Lancashire and S. Cumbria (nursing, family support and service coordination)

PROGRAMME 2- Greater Manchester (nursing, family support, service coordination and counselling)

Date of referral to Kentown Support:

Day

Month

Year

Referrer Details:

First Name

Surname

Email

Phone

Job role of Referrer

Reason for referral

Child Details:

Child's First Name

Child's Surname

Child's Address

Date of Birth (For antenatal referrals provide date of delivery)

NHS Number (If child is an antenatal referral, input mother's NHS number)

Gender

Male

Female

Ethnicity

Black, Black British, Caribbean or African

Caribbean

African

Any other Black, Black British or Caribbean background

Mixed or multiple ethnic groups

White and Black Caribbean

White and Black African

White and Asian

Any other mixed or multiple ethnic background

Primary Parent/Carer Details:

First Name

Surname

Phone

Email

Does parent live at same address as child?

Yes

No

Relationship to child

If 'Other', please state

Who is the support for?

First and Last Name

Age

Relationship to Child (if different to main child, eg. sibling, grandparent)

Contact Details (if different to parent contact details)

Are there any safeguarding issues?

Yes

No

Is an interpreter required?

Yes

No

If 'Yes', please state preferred language

Are there any risks to lone workers visiting this family?

Yes

No

Any other information relevant to referral?

NOTE: At present, our Greater Manchester programme is only accepting referrals for Counselling.