Patient Referral Form

https://project.butterwick.org.uk/wp-content/uploads/2019/08/Day_Care_Refferal_Form.pdf

Your details

By adding your email address you will be helping the Charity to save costs. You are also agreeing to Butterwick Hospice Care contacting you by email.

By adding your email address you will be helping the Charity to save costs. You are also agreeing to Butterwick Hospice Care contacting you by email.

By adding your email address you will be helping the Charity to save costs. You are also agreeing to Butterwick Hospice Care contacting you by email.

Next of kin

Any distant spread, e.g.: Metastases in Liver:

*Please attach any recent clinic letters with this referral*

Volunteer Roles

'St' refers to Butterwick in Stockton. 'BA' refers to Butterwick in Bishop Auckland

About You

Please use this section to tell us about yourself so that we can identify a role/location to best suit your skills and motivations. Previous experience or skills are not required as training will be given.

Health declaration

The information you provide will assist us in discussing with you any risk reduction measures we may be able to introduce as a result of identified health concerns. Your response may prompt us to request guidance from your GP, with your permission, and only where we have concerns regarding your health and safety to carry out the duties associated with your chosen voluntary position.

Disclosure of criminal convictions

Butterwick is committed to equal opportunity for all volunteer applicants including those with criminal convictions. Information about criminal convictions will be taken into account ONLY when the conviction is considered relevant to the role. In accordance with the Rehabilitation of Offenders Act 1974 certain volunteer roles are exempt and criminal convictions, in these circumstances, MUST be declared. Any disclosure will be seen in the context of the criteria for the role, the nature of the offence and the responsibility for the care of existing patients, volunteers and employees. In the event of recruitment, any failure to disclose this requested information where this is appropriate to the role, could result in dismissal. A copy of the Organisation's Recruitment and Retention of Offenders and Ex-Offenders Policy is available upon request.

If you have any questions about this please contact the Voluntary Services Manager on 01642 607742

References

Please provide us with the details of two referees who from personal knowledge are able to comment on your suitability for volunteering. These can be friends, neighbours or colleagues but NOT family members and must be 18+ years of age. Insufficient address information may result in a delay in your application.

Declaration

In accordance with the Date Protection Act 1998, I give my consent for the information in this form to be processed by Butterwick for the purposes of volunteering. I understand that if I am offered a volunteering role, this application form will become part of my volunteer file and record. If I am not offered a role, it will be stored for three months and then destroyed. I understand that Butterwick may carry out a Disclosure and Barring Service check, may require me to undertake training relevant to the role, and expects me to follow organisational policies and procedures. I certify that the information given on this form is correct and that should any false statements or omissions be made, a volunteer role may not be offered.

Equal opportunities monitoring form - please complete

We welcome interest from any person who wishes to volunteer at Butterwick and seek to reflect the diversity of our community in terms of race, culture, gender, sexuality, age and disability. This information is used only for the purposes of ensuring the effectiveness of our Equal Opportunities Policy, which is available on request, and will not be used in the recruitment process. Any information you provide will be strictly confidential.

Disability

The Disability Discrimination Act 1995 defines a person as disabled if they have a physical or mental impairment which has a substantial and long term (i.e. has lasted or is expected to last at least 12 months) adverse effect on one's ability to carry out normal day-to-day activities.

Religion or belief. How did you find us