Skip to main content
Carers' Resource
You are here
Home
HFH NY Referral
1
Start
2
Complete
Referrer Details
First Name
*
Last Name
*
Job Title
*
Phone Number
*
Email
*
Referring Organisation
Find Referring Organisation
Organization Name
*
Client Details
First Name
*
Last Name
*
Gender
*
- Select -
Female
Male
Transgender
Non-binary
Other
Prefer not to say
Birth Date
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Street Address
*
Street Address Line 2
Street Address Line 3
City
County
Postal Code
*
Phone Number
*
NHS Number
*
Further Demographics
Ethnicity
- None -
Afghani
Arab
Asian / British Asian:Bangladeshi
Asian / British Asian: Indian
Asian / British Asian: Pakistani
Black / Black British: African
Black / Black British: Caribbean
Chinese / British Chinese
Eritrean
Gypsy
Irish Traveller
Kashmiri
Kurdish
Mixed White and Asian
Mixed White and Black African
Mixed White and Black Caribbean
Not Provided
Other: White
Other Asian Background
Other Black Background
Other Ethnic Group
Other Mixed Background
Other White Background
Prefer not to say
Rohingya
Roma
Vietnamese
White Albanian
White and Asian
White British
White Bulgarian
White Croation
White Czech
White East European
White English
White Estonian
White Hungarian
White Irish
White Latvian
White Lithuanian
White Northern Irish
White Polish
White Romanian
White Scottsh
White Slovakian
White Welsh
Age Group
- None -
18-64
65-74
75-84
85+
HFH NY Case
Referring Hospital
- None -
Airedale General Hospital
Bradford Royal Infirmary
Castle Hill Hospital, Cottingham
Darlington Memorial Hospital
Friarage Hospital, Northallerton
The Friary Community Hospital, Richmond
Harrogate District Hospital
James Cook University Hospital
Malton Community Hospital
Ripon and District Community Hospital
Scarborough Hospital
Selby War Memorial Hospital
Whitby Hospital
York Hospital
Other
GP Practice
District
*
- Select -
Craven
Hambleton
Harrogate
Richmondshire
Ryedale
Scarborough
Selby
Admission Reason
*
Hospital Admission Date
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
Hospital Discharge Date
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
Referral Category
- None -
Discharge Hub
HASS - NYCC Reablement Team
HASS - Other
Health & Adult Services
Health - GP
Health - Hospital
Health - Medical Practice
Health - Rapid Assessment Team
Other
Self
Voluntary Agency
Pathway
*
- Select -
0 = Going home without support
1 = Going home with support
2 = Temporary bed setting e.g. rehab
3 = Complex
Patient already at home?
*
Yes
No
Is there a homecare package?
*
Yes
No
Have you also referred the patient to any other agencies? Please give details if so:
Lives with?
Alone
Care Home
Lodger
Sibling (Brother/Sister)
Son/Daughter
Spouse/Partner
Parent(s)
Who supports this person, e.g. spouse, carer, friend, neighbour?
Is Carer?
Yes
No
Is Cared For?
Yes
No
Primary Incapacity
*
- Select -
Dementia
Dual Sensory Loss
Frailty/Temporary Illness
Hearing Impaired
Learning Disability
Mental Health
Other - Loneliness & Isolation
Physical Disability
Substance Misuse
Visually Impaired
Any cognitive impairment/dementia?
*
Yes
No
Covid-19 Diagnosed?
*
Yes
No
Support required after discharge?
Is feedback required?
*
Yes
No
Safeguarding, Health & Safety and key information
Are there any safeguarding concerns, or other safety issues with this referral?
Yes
Subject
*
Details of Safeguarding Concern
*
Absconding
Aggression & intimidation
Child Criminal Exploitation
Child Sexual Exploitation
Domestic Abuse
Emotional Abuse
Financial abuse
Neglect
Sexual Abuse
Physical Abuse
Sexualised Behaviour
Substance Misuse
Vulnerable adult exploitation
Other
Safeguarding Alert
*
- Select -
Vulnerable Adult
Child Protection
Not safeguarding - Adult (not vulnerable)
Details
*
Leave this field blank