Sebastian’s Action Trust Professional Referral Form Our criteria for taking on new referrals are that the child must have a life-shortening condition according to NICE Guidelines: Group 1 – Life threatening conditions for which curative treatment may be feasible but can fail. (E.g. cancer, irreversible organ failures of heart, liver, kidneys.) Group 2 – Conditions where premature death is inevitable. (E.g. cystic fibrosis) Group 3 – Progressive conditions without curative treatment options. (E.g. Batten disease, mucopolysaccaridoses, muscular dystrophy.) Group 4 – Irreversible but non-progressive conditions causing severe disability leading to susceptibility to health complications and likelihood of premature death. (e.g. multiple disabilities such as brain or spinal cord insult.) On receipt of the referral, a medical professional will be contacted to confirm diagnosis meets our criteria. Child’s full name Child's date of birth Gender Male Female NHS Number Child’s Condition Home Address County Postcode Mum’s Name Contact Number/ Email Dad’s Name Contact Number / Email Referred by Name: Telephone: E-mail:
Sebastian’s Action Trust Professional Referral Form Our criteria for taking on new referrals are that the child must have a life-shortening condition according to NICE Guidelines: Group 1 – Life threatening conditions for which curative treatment may be feasible but can fail. (E.g. cancer, irreversible organ failures of heart, liver, kidneys.) Group 2 – Conditions where premature death is inevitable. (E.g. cystic fibrosis) Group 3 – Progressive conditions without curative treatment options. (E.g. Batten disease, mucopolysaccaridoses, muscular dystrophy.) Group 4 – Irreversible but non-progressive conditions causing severe disability leading to susceptibility to health complications and likelihood of premature death. (e.g. multiple disabilities such as brain or spinal cord insult.) On receipt of the referral, a medical professional will be contacted to confirm diagnosis meets our criteria. Child’s full name Child's date of birth Gender Male Female NHS Number Child’s Condition Home Address County Postcode Mum’s Name Contact Number/ Email Dad’s Name Contact Number / Email Referred by Name: Telephone: E-mail:
Professional_Referral_Form_2018.docx