Download referral form

Referrals to all of our services can now be done using just one form.

Download the form to refer to the following services:

Complete forms should be emailed using an account to [email protected]

Referrals can still be faxed but please be aware that the Hospice will be phasing out fax communication in the near future.

  • Hospice at Home secure fax number – 0121 471 2079
  • CNS Team secure fax number – 0121 472 4159

If you have any queries or would like any advice regarding new referrals, our Triage Nurse, Rachel Shuttleworth, is available Monday to Friday (8.00am to 4.00pm) on 07726 580153.

Download referral form