CPOC6C Referral Form Combined

Children’s Complex Packages of Care R e f e r r a l F o r m

It is important that this form is FULLY completed. Please check that all details are checked prior to sending to avoid any unnecessary delay. Incomplete forms will be returned causing delay in processing.

Biographical Details: NHS Number:

Surname: Other name(s):

Gender: Date of Birth: Age:

Full Address including Postcode:

Full Address of current location including Postcode and Telephone Number if not at home:

Ethnicity: Religion: First Language: Next of Kin details: Full name: Full address including Postcode: Phone number(s):

Relationship:

Who has Parental Responsibility? Full name: Full address including Postcode: Phone number(s):

Relationship:

CPOC Form 2 Additional Person/Carer details: Full name: Full address including Postcode: Phone number(s):

Relationship:

GP Details: GP Name: GP Address including Postcode: GP Phone Number:

Practice Code:

CAF Details:

CAF completed: YES/NO If YES please attach copy

Date CAF completed: Unique Reference No:

Date of Team Around a Child meeting (TAC) where the need for a referral was identified:

Has the parent/carer agreed to the referral? YES/NO

Case Manager (or Lead Professional as per CAF) Details if CAF completed: Full name of Case Manager (Referrer’s Case Manager (Referrer’s Designation) Contact Designation): Details including Email address:

CPOC Form 2 Referrer Details: Full name of Referrer/Designation: Referrer/Designation Contact Details including Email address:

Referral Details: (this information MUST be provided): Reason for Referral (please double click inside box to select ‘Checked’):

Medical Device Consumables Health Needs Assessment

It is essential that you indicate ALL that apply

Diagnosis/Medical History:

Equipment/Consumables Requirement (please complete Appendix) and Rationale:

Any risk issues that CPOC need to be aware of including safety of Home Visits:

CPOC Form 2 If a Saturation Monitor is required please answer the following questions fully?

1) Who will be medically responsible for overseeing the child’s care in the community?

2) What parameters is the monitor to be set at?

Heart Rate HIGH LOW

Oxygen Saturation HIGH LOW

3) Is the child on oxygen therapy? YES NO (please double click inside box to select ‘Checked’)

 If YES please provide a copy of the HOOF with details of their oxygen requirements.

4) What protocols are in place for the patient to follow in the event that their saturation level should fall?

5) When should the saturation monitor be used: 24 hours a day, spot checks or overnight?

6) Are the parents/carer’s trained in basic life support and if so who will provide ongoing training and up dates?

Please email the completed Referral form to: [email protected] CPOC Form 2 Childrens Complex Packages of Care 5th Floor St Peter’s Primary Health Care Centre Church Street BURNLEY Lancashire BB11 2DL

Tel: 01282 628414 Fax:01282 628432

FOR OFFICIAL USE ONLY

Date Received: Date Referral Accepted:

Response letter sent to referrer: To client:

Registered:

CPOC Form 2 Please complete first two columns ONLY: Total Cost Product Description Quantity Required Unit Price (including VAT)

CPOC Form 2