<p> Community Specialist Palliative Care Team Referral Form</p><p>Mr/Mrs/Ms/Miss/Other: NHS Number: Surname: Marital Status: Ethnic Group: Forenames: Next of Kin/Carer:</p><p>Known as: Relationship: DOB: Age: M / F Contact Number: Address: Referrer Name:</p><p>Designation/Place of Work: Postcode: Telephone: Telephone:</p><p>Lives Alone Y / N Date of Referral: GP: Consultant: DN: Other: Current Location of Patient: Is the patient aware Is GP aware of this of this referral? Y / N referral? Y / N Diagnosis: Site of any Metastases (if applicable)</p><p>Date of Diagnosis: Reason for Referral: ☐ Other please state: ☐ Pain ☐ Terminal Care ☐ Emotional/Psychological Support Urgent (contact within 2 working days) ☐ ☐ Symptom Control (please specify below) Routine (contact within 7 days) ☐ Main Symptoms/Problems:</p><p>Any Other Relevant Information:</p><p>In the event that all information is not supplied we will need to contact you which may result in a delay. Updated 12/07/16 DH</p>