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t: 01978 316800   e: info@nightingalehouse.co.uk
t: 01978 316800  e: info@nightingalehouse.co.uk
Access Services
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Self refer

Accessing our services

We understand that you may want to access our services quickly, and sometimes, there is a wait involved when asking a medical professional for a referral. Accessing our services should be simple, that’s why we offer the option for the patient or a family member to refer to our services. 

Our Patient Flow Team is on hand to help and support you in accessing our many excellent services; whether that be a period of respite, wellbeing, physiotherapy, complementary therapy, symptom management, family support, or end-of-life admission, we’re here to make your introduction to the hospice easy. 

What is a self referral?

If you’d like to access our services, you can reach out to us directly – there’s no need to go through a healthcare professional first. You, a family member, or a caregiver can complete our self referral form below, or give our team a call on 01978 316806.

Once we’ve heard from you, we’ll get in touch with your primary care provider, such as your GP or district nurse, to confirm your referral and gather the clinical information we need to support you in the best possible way.

We will keep you informed of the progress of your referral every step of the way.    

By using the self referral process, we hope this will enable you to access our services more quickly. 

You can complete the self referral online using the form below, or if you prefer, download and print a copy to bring directly to Nightingale House Hospice.

Self Referral form
download form

Please call us and ask to speak to a member of our Patient Flow Team on 01978 316806 if you have any questions. 

The Patient Flow Team are available between 9am and 4pm, Monday to Friday (excluding Bank Holidays). 

Self-Referral Form

N.B. Please provide as much detail as possible. If urgent advice is needed please contact 01978 316806 (Mon-Fri 9am-4pm) or 01978 316808 (Out of hours)

Has the patient consented to this referral being made?
Has the patient given consent to access their medical records and to speak with other healthcare professionals?

Patient Details

Date of Birth
Address
Current location of Patient
Please state in ‘Other’ if patient lives alone and enter other location below:

Details about Referral

Please indicate which service(s) are required:
If this is an URGENT referral for admission, please call the numbers above once you have sent the form.

Confirmation Details

Clear Signature
Date form completed:
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