SPC Palliative Care Referral Form

Patient Details

Note: Questions marked by * are mandatory

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Northants Community Specialist Palliative Care Single Point Referral Form

Please provide as much information as possible to support this referral. eg recent letters, scan reports etc
Incomplete forms cannot be accepted, we may need to contact the referrer for more information
Referral criteria for Community Specialist Palliative Care (SPC) Team
All of below:
  • Patient has progressive, life limiting diagnosis
  • There is complex symptom control, complex functional or psychological issues important to the patient, that cannot be readily managed by the team responsible for care
  • The patient agrees to referral to the Community SPC team, if competent to choose

    • If the patient is felt to be in last four weeks of life and requires Hospice @ Home support, do not complete this form. Please telephone 0300 027 1284 to make a referral



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