I am* Please select which service is required* Please note: Fatigue and Breathlessness is a day therapy...
I wish to refer to* Patients may self-refer to the services below, and family members or friend can complete this for you with your consent.
Temporary pause on referrals to our Patient and Carer Wellbeing Service
Due to high demand, we will be temporarily pausing new referrals to The Myton Hospices Patient and Carer Wellbeing Service from midday on Monday 7th April. We sincerely apologise for any inconvenience or disappointment this may cause. This situation will be reviewed on Tuesday 6th May, and we will provide an update on our website. Thank you for your understanding and support. Please do not try to fill out the form during this time as it won’t allow you to submit a referral.
Unfortunately, this service is no longer in operation. I wish to be referred to (OLD)* You can select multiple
Unfortunately due to the Coronavirus outbreak this service is temporarily suspended, We are really sorry and hope to be back up and running soon. Preferred location* Self referral / referring a loved one* I confirm I have the consent of the patient to submit a referral on their behalf:* Is the patient happy for us to contact them* Does the patient consent for us to contact outside agencies who are involved with their care e.g. GP, Community Nurse?*
Your details
Patient details (OLD) Patient gender
GP details (OLD) Persons Diagnosis (including current treatment):* Other relevant medical history: Does the patient have any goals you hope the Living Well Project will support you to achieve? Is the patient previously been known to the Day Unit?* When was the patients last visit?
What is the patient hoping to gain from attending the Day Unit (from therapy days)?
Is there any other information you feel would be useful for us to know before we meet you? Preferred location*
Reason for Referral Please detail below essential information to outline the patient’s need;* e.g. Uncontrolled symptoms, complex emotional/psychosocial /spiritual support required.
Please include details of main symptoms/severity and what treatment plan is currently in place* e.g. syringe driver, summary of medications, type of pain
Urgency of referral*
If same day (emergency admission) – please do not continue this form please call: Monday – Friday, 8am - 4pm please call Referrals and Discharge on 01926 838889 Anything outside of these hours please call Warwick Myton Reception on 01926 492518 and ask for an Inpatient Unit Senior Nurse or follow the voicemail instructions. You will not be able to progress any further with this referral. Does the patient referred have a Coventry or Rugby GP?* Does the patient referred meet the criteria for fast-track funding?* Has CHC funding has been agreed?*
Reason for Referral The patient cannot be cared for in their own home or are not able to be cared for in an alternative place of nursing care due to their specialist palliative nursing and/or supportive care needs?* The patient referred does not require medical assessment or regular medical intervention i.e. they should be medically stable for discharge if in hospital or the hospice?* DNACPR in place?*
Myton at Home
We understand that many patients want to be cared for in the comfort of their own home, surrounded by family and friends, so our Myton at Home service is designed to enable patients to remain in the comfort of their own home and be supported in their final weeks or days of life.
Respite Bed
Patient and Carer Wellbeing Service
Is the patient registered with a Rugby, Warwick or Leamington GP?* Urgency of referral*
If same day response – please do not continue this form please call:
01788 550085 between the hours of 8.30am-4.30pm Monday to Friday.
You will not be able to progress any further with this referral.
Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.
Please call our referral team where we will try to direct you to an alternative service: Monday – Friday, 8AM - 4:00PM please call Referrals and Discharge Clinical Nurse Specialist on 01926 838889 Saturday - Sunday – 9AM - 5:00PM please call our Myton at Home team: For Rugby: 01788 551516 / Warwick: 01926 838814 You will not be able to progress any further with this referral. Patient title* Patient address* Please enter the full address and postcode...
Preferred Location to be seen* Is the patient able to attend The Myton Hospices?* Please provide further details on why the patient is unable to attend The Myton Hospices.*
Patient agrees to referral?* Consent to access shared GP records?* Reason for Referral? You may select multiple reasons.* What is the most important thing for the patient regarding this referral?*
Does the patient have specific goals they wish to achieve by accessing the Patient and Carer wellbeing service? If so please let us know more...
Next of Kin (NOK) Details Next of Kin address* Please enter the full address and postcode...
Carer Details Carer address* Please enter the full address and postcode...
Please provide details of existing care package*
Is the patient highly dependent on their carer in the home setting?*
Medical information Medical history* Please provide as much detail as you know as this is incredibly helpful to us...
What it the patient’s current clinical situation?*
Please summarise any other significant medical and/or mental health problems including any recent or past treatments*
Does the patient speak and understand English?* Does the patient have any allergies?* Are there any infection risks? If so please tell us more*
Does the patient require any respiratory support?* For example non-invasive ventilation (NIV), continuous positive airway pressure ventilation (CPAP),oxygen, nebuliser...
Does the patient have a ReSPECT form?* Does the person have capacity to consent to admission?* Reason for Referral? You may select multiple reasons.* *Please note for a carer to access support, the person with the illness must accept a wellbeing assessment.
What is the most important thing to the patient in regard to this referral?*
What are the patient’s short-term goals in regards to this referral?*
What are the patient’s main concerns or issues and do they have any specific goals they wish to achieve through this service?*
Any other medical information you wish for us to know (optional)
Are they able to attend The Myton Hospices?* Please provide more information as to why?* For example: bed bound, work commitments, lack of transport etc.
Would the patient be willing to attend a group session?* Are they accessing any other services? E.g District Nurse, OT/Physio, Specialist Palliative Care Nurse, Counselling, Care Package etc.*
Patients phase of illness*
This patient would not be suitable for Wellbeing, please call our Referrals Team on 01926 838889 to discuss the needs and concerns of the patient as may be appropriate for Myton at Home or Inpatient Unit
Respite request Is there an alternative week/flexibility in the dates?* Does the person have their own transport to and from the hospice?* If no, we request this is arranged and booked by yourselves...
Referrer details Who is making this referral?* Who is making this referral?* How did you hear about this service?* You may select multiple
I have read and accept The Myton Hospices Privacy Policy* Is the patient registered with a Rugby, Warwick or Leamington GP?*
Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.
Please call our referral team where we will try to direct you to an alternative service: Monday – Friday, 8AM - 4:00PM please call Referrals and Discharge Clinical Nurse Specialist on 01926 838889 Saturday - Sunday – 9AM - 5:00PM please call our Myton at Home team: For Rugby: 01788 551516 / Warwick: 01926 838814 You will not be able to progress any further with this referral. Is the patient known to a community nursing team?*
Please ensure that you make a community nurse referral as well as completing this form. Is the patient in their last 2-4 weeks of life?*
Reason for Referral To facilitate hospital / hospice discharge* To prevent hospital/hospice admission* Personal Care You can select multiple here.
Respite Sit* Psychological care* Urgency of contact*
If same day response – please do not continue this form please call:
01788 550085 between the hours of 8.30am-4.30pm Monday to Friday.
You will not be able to progress any further with this referral. Visits required?* You can select multiple here.
Does the patient have a syringe driver in situ?* Equipment currently in place?* You can select multiple here.
Please state what other equipment currently in place* Continence details?* You can select multiple here.
Nutrition needs?* Mobility* Preferred location* Patient transport* Reason for referral* What are you hoping this individual will gain from this experience?* Preferred location* Patient diagnosis (including current treatment)* Relevant co-morbidities / past medical history* Other health and social care professionals known to this person. Please state names and contact details.* What do you hope the person will gain from attending our Living Well programme?* Does the patient have a ReSPECT form?* Preferred location* Primary diagnosis underlying participant’s breathlessness* Relevant co-morbidities/past medical history* What do you hope the participant will gain from this course?* Does the patient use oxygen?* Does the patient have a ReSPECT form?* I confirm the participant is aware of this referral, the need to bring their own ambulatory oxygen and provide their own transport* Which part of the body is affected?*
Lymphoedema treatment to date
Known metastatic sites (if applicable)
Does the patient have any allergies or sensitivities?* Please tell us more about the patients allergies or sensitivities*
What is the most recent CPR decision* Is the patient attend the clinic or is the patient housebound?*
The patient may qualify for a home visit. Please continue the form. Any requirements specify to patient (e.g. hearing/sight/care needs)*
