If you would like to refer a patient, please download and complete the relevant online Referral Form from the list below:

Please note - clicking the pink buttons below will download the form and store it in your selected 'Downloads' folder

Referrals to our Day Hospice, Inpatient Unit, Hospice at Home and Community Palliative Care services and Transfusion Clinic

Day Hospice services referral form (inc. Therapeutic Programme and Welcome Group)

To find out more about our Day Hospice please click here

Inpatient Unit and Community Palliative Care referral form

Find out more about the Inpatient Unit by clicking here

For information about Community Palliative Care please select this link

Completed forms for all other referrals should be sent to:

Email: [email protected] 

Fax: 0121 472 4159


Referrals to our Hospice at Home service

Hospice at Home trigger form

Hospice at Home referral form (Integrated Multidisciplinary Team)

Completed Hospice at Home referrals should be sent to:

Fax: 0121 471 2079

If you have any queries or would like advice regarding new referrals, our Triage Nurse, Rachel Shuttleworth, is available Monday to Friday (8.00am to 4.00pm) on 07726580153.