Healthy & Home St Helens Referral

St Helens Healthy and Home aim to ensure that patients are aware of the voluntary sector organisations that exist, and how they can enable them to remain happy and safe following their discharge from the Hospital.

The project also aims to support prevention of hospital readmission.

If you would like to discuss your referral before completing the form, call: 07721 619887

 Our Criteria for referrals:

Those living in the St. Helens area.

All referrals to Healthy and Home must be over 18 years old.

Only to be completed with CONSENT TO REFER

Details of person completing this form (Referrer):

Name: ^*

Telephone: ^*

Email: ^*

Referring Organisation:

Patient Details

Patient Name: ^*

Preferred Name:

Gender

Date of Birth: ^*

Home Address: ^*

Postcode: ^*

Email:

Telephone Number: ^*

NHS Number: ^*

GP Practice: ^*

Preferred contact method:

Email

Text message

Phone call

Best time to contact:

We can only accept a referral if we have the patients consent.

Healthy & Home St Helens Referral

Only to be completed with CONSENT TO REFER

Details of person completing this form (Referrer):

Patient Details

Consent

Authorised contact:

Referral Details: