Professional Referrals

1. Todays Date

Day

Month

Year

Enter todays date

2. Name of Client

3. Address of Client

4. Contact Number

5. Is the above contact number the clients number?

Yes, please contact

No

6. If you answered No above, please state the contact name and the relationship to the client

7. Client Date Of Birth

8. Client Diagnosis

9. Please state where the client is currently being cared for (including ward, if appropriate)

10. Please tick the appropriate box with respect to patient Prognosis

Red (Imminent)

Amber (up to 3 months)

Green (6 months +)

C (only tick if the patient has no capacity)

11. Referrer Name

12. Referrer Email Address

13. Referrer Telephone Number

16. Has Advanced Care Planning been discussed

Yes

No

17. Special Features - eg client is unaware of prognosis and doesn't want to know; client doesn't want partner to know of referral

18. Please ADD additional matters that are not referred to on this form

19. How many people were present at the meeting?

20. LegaCare is a charity and our funders would like to know what impact we make on people in the Community. Can we ask two simple questions before we start.

Question 1 - On a scale of 1-10, 1 being not so much and 10 causing you a lot of stress, can you describe how stressful the current situation is causing you.

Question 2 - Can I ask if you had not had access to LegaCare what would you have done? eg visit another solicitor, another charity, done nothing or someone else.

22. Any other comments

24. Please let us know if you have any suggestions as to what we could have done differently/better