Children's Palliative Care Team - Referral Form

This form must be completed with parent/ carer and if appropriate the child/ young person and then emailed to:

Ulth.childrens-palliative-care-team@nhs.net

Children's Palliative Care - Referral Form

Children's Palliative Care Team- Short Breaks Criteria for Referral to the Service

This service  provides care for the child or young person in their home whilst their parent/ carer have a short break from caring. All new referrals will receive an initial assessment visit from the Team Leader within 2 weeks from receipt of the completed referral form. All new referrals are reviewed at the monthly team meeting to allocate a Children’s Palliative Care Support Worker and hours to support the family.

Children’s Palliative Care Team- Short Breaks Referral Criteria .docx

Child and Young Person's Advance Care Plan

Plans can begin antenatally (using ante-natal version of this document) and are suitable for infants, children and young people.
This form should be used across all settings.

Last updated: April 2024 v.5 

CYP Advance Care Plan Form

For more information and guidance see the CYPACP website:

CYPACP website