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Home COAST test 3

COAST test 3

COAST (Children's Outreach and Symptom Team) - 3

Specialist paediatric palliative care in Sussex

CONSENT

Has the parent/legal guardian agreed to this referral? We are unable to process referrals without this consent.(Required)

Yes

Referral type:(Required)

Consultant to Consultant referral

Other professional

Name of referrer:(Required)

Referrer email:(Required)

Enter Email Confirm Email

ABOUT THE CHILD / YOUNG PERSON

First name:(Required)

Last name:(Required)

NHS number:(Required)

This is a 10-digit number. Please use mother's NHS number if this is an antenatal referral.

Gender:

Date of birth:(Required)

Ethnicity:

Religion:

Please specify:

Home address line 1:

Home address line 2:

Town/City:

County:

Post code:

Please use the anticipated home address if the referral is antenatal.

Is the child/young person aware of this referral?

Yes

No

N/A

ABOUT THE PRIMARY PARENT / CARER

First name:(Required)

Last name:(Required)

Relationship to child:(Required)

Date of birth:

Parental responsibility?(Required)

Yes

No

Same home address as child?(Required)

Yes

No

If antenatal, this would be the intended home address

Email:(Required)

Enter email Confirm email

First language:(Required)

Interpreter required?(Required)

Yes

No

Phone number:(Required)

PRIMARY PARENT / CARER ADDRESS

Home address line 1:

Home address line 2:

Town/City:

County:

Post code:

Add another parent/carer?(Required)

Yes

No

ABOUT THE PARENT / CARER 2

First name:(Required)

Last name:(Required)

Relationship to child:(Required)

Date of birth:

Parental responsibility?(Required)

Yes

No

Living with child / young person?(Required)

Yes

No

Email:

Enter email Confirm email

First language:(Required)

Interpreter required?(Required)

Yes

No

Phone number:

PARENT / CARER 2 ADDRESS

Home address line 1:

Home address line 2:

Town/City:

County:

Post code:

ABOUT THE SIBLINGS

Does the child / young person have any siblings?(Required)

Yes

No

Unsure

Please provide any relevant information(Required)

For example, younger/older siblings, any sibling with similar conditions

ABOUT THE REFERRAL

Please contact the COAST team on 01903 871802.

Is this referral:(Required)

Urgent

Routine

Reason for referral:(Required)

Primary diagnosis:(Required)

Add another diagnosis?

Yes

No

Second diagnosis:(Required)

Add another diagnosis?

Yes

No

Third diagnosis:(Required)

Add another diagnosis?

Yes

No

Fourth diagnosis:(Required)

Add known allergies?

Yes

No

Allergy details(Required)

Is there an Advance Care Plan / RESPECT document in place?(Required)

Yes

No

Please upload the Advance Care Plan / RESPECT document if available

Drop files here or

Max. file size: 54 MB.

Is there a SMP in place?(Required)

Yes

No

Is the child / young person subject to current or previous safeguarding concerns?(Required)

Yes

No

Please select all that apply:(Required)

Domestic abuse within the family home

Significant mental health issues in parent or carer

Interim care order

Full care order

Residence order

Other

If Other, please specify:

Please provide details of concerns:

PAEDIATRICIAN

Is the child / young person under the care of a hospital paediatrician?(Required)

Yes

No

PAEDIATRICIAN DETAILS

Prefix:

First name:

Last name:

Hospital name:

Hospital address line 1:

Hospital address line 2:

Town:

County:

Post code:

Phone number:

Email:

Enter email Confirm email

HOSPICE SERVICE / PALLIATIVE CARE TEAM

Is the child / young person known to any hospice service or palliative care team?(Required)

Yes

No

HOSPICE SERVICE / PALLIATIVE CARE TEAM DETAILS

Prefix:

First name:

Last name:

Hospice/care team name:

Address line 1:

Address line 2:

Town:

County:

Post code:

Phone number:

Email

Enter Email Confirm Email

GP

Do you know who the child / young person's GP is?(Required)

Yes

No

GP DETAILS

Prefix:

GP first name:

GP last name:

GP practice name:

GP practice address 1:

GP practice address 2:

Town:

County:

Post code:

Phone number:

Email:

Enter email Confirm email

OTHER PROFESSIONAL DETAILS

Prefix:

First name:

Last name:

Job title:

Organisation name:

Address line 1:

Address line 2:

Town:

County:

Post code:

Phone number:(Required)

Email:

This can be an individual’s email or one for a relevant team

Enter email Confirm email

SUPPORTING DOCUMENTS

Please provide any relevant supporting documents such as clinic letters and discharge summaries to help us make a fully informed decision.

Drop files here or

Max. file size: 54 MB.

FURTHER INFORMATION

Please add any further information, if applicable:

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By providing your details you confirm you're over 18 years old

Please complete the fields below:

Your email address*:

Title *

First name *

Last name *

Postcode *

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Training courses

Working here

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Get involved

Volunteer

Show Your Love

About the organisation

Working here

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COAST test 3

COAST (Children's Outreach and Symptom Team) - 3

CONSENT

ABOUT THE CHILD / YOUNG PERSON

ABOUT THE PRIMARY PARENT / CARER

PRIMARY PARENT / CARER ADDRESS

ABOUT THE PARENT / CARER 2

PARENT / CARER 2 ADDRESS

ABOUT THE SIBLINGS

ABOUT THE REFERRAL

PAEDIATRICIAN

PAEDIATRICIAN DETAILS

HOSPICE SERVICE / PALLIATIVE CARE TEAM

HOSPICE SERVICE / PALLIATIVE CARE TEAM DETAILS

GP

GP DETAILS

OTHER PROFESSIONAL DETAILS

SUPPORTING DOCUMENTS

FURTHER INFORMATION

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