Please fill out the form below if you would like to refer someone to us online. If you would prefer to download the form and fill it out, please do so and then email or post it to us.

Download the form

You can download the Referral form here:

Download Form

    *indicates required fields

    Child / Young Person's Details

    Is the condition life threatening?

    Is the condition life limiting?


    Services Required

    Care (short breaks, clinical or social care and support in the community)Family Support (advocacy, social or emotional support, etc.)Family Days (days out for the whole family)Parent Groups (facilitated peer support for parents/carers)Sibling Groups (activities for siblings)Children’s Groups (activities for the child being referred on this form)Volunteer Support (regular visits for social, befriending or practical support)Complimentary Play and Therapies (sessions with a Play Specialist or Therapist)Bereavement Support (Care, Complimentary Play and Therapies, Family Support)


    GP Details


    School Details


    Parent's/Carer's Details

    Parent/Carer 1

    Do you have Parental Responsibility?

    Parent/Carer 2

    Do you have Parental Responsibility?


    Sibling Details

    Sibling 1

    Sibling 2

    Sibling 3


    Referrer’s Details

    How did you hear about Forever Colours?
    Already working in partnershipForever colours PresentationFamily or FriendSocial mediaLocal professional networkingForever colours Fundraising EventOther (please state below)


    Additional Information

    Please give a brief description of how you feel Forever Colours Children’s Hospice can help the child/young person and family referred. Please include any additional information you feel would be helpful with this referral.

    Is there anything Forever Colours need to be aware of before contacting the child/young person/family?

    What languages are spoken at home?

    Is an interpreter required?


    Referral Consent and Privacy

    For those unable to consent and children under 16, please confirm you give consent to this referral:

    For young people aged 16 years above:

    Does the young person have capacity to consent to the referral?
    YesNo

    If the young person has capacity to consent, please confirm they have given consent to this referral:

    In order to provide safe and effective care, Forever Colours Children’s Hospice will need to obtain or share up to date personal details, and general medical and social care information, including clinic letters, copies of prescriptions (FP10), emergency care plans and advance care plans from other professionals including (but not limited to) schools, community teams, GPs, hospitals, local authorities and/or clinical commissioning groups.

    Thank you for your time. Please submit your referral ensuring you have checked the relevant consent boxes above.