Unique ID

Section A

Service type and location request

We are sorry but only healthcare professionals can make a referral using this form. Please check "the services that we provide" page for more information about our services and how to refer by clicking here.

Unfortunately, this service is no longer in operation.

We have been offering similar support within our Patient and Carer Wellbeing Service which healthcare professionals, patients, families and carers can make a referral by contacting the referrals team on 01926 838889 between 9.30-1,30pm Monday to Friday (excluding bank holidays).

We are currently reviewing our online referral process.

Self referral (OLD)

Patients may self-refer to our Therapeutic Days (Day Unit) and the Living Well Programme.

A family member or friend can complete this for you with your consent.

Unfortunately due to the Coronavirus outbreak this service is temporarily suspended, We are really sorry and hope to be back up and running soon.

At this moment in time you cannot refer to this service.

Your details

Your first name*

Your surname*

Your telephone number

Your mobile number*

Your email

Patient details (OLD)

Patient first name*

Patient surname*

Patient address line 1*

Patient address line 2

Patient city/town*

Patient postcode*

Patient date of birth*

Patient telephone number

Patient mobile number*

Patient NHS number

Patient email

GP details (OLD)

GP first name

GP surname

GP practice*

GP address line 1

GP address line 2

GP city/town

GP postcode

GP telephone number

Persons Diagnosis (including current treatment):*

Other relevant medical history:

Does the patient have any goals you hope the Living Well Project will support you to achieve?

When was the patients last visit?

What is the patient hoping to gain from attending the Day Unit (from therapy days)?

Is there any other information you feel would be useful for us to know before we meet you?

Inpatient Medical Bed

Myton has two inpatient units in Warwick and Coventry. Both have teams of nurses, doctors and other health care professionals. Admission will be considered for any patient aged 18 years or over, with specialist palliative care needs due to advanced, progressive, life limiting disease. The patient should be registered with a Coventry or Warwickshire GP to access the inpatient unit beds. The Myton Hospices do not provide long term care.

Reason for Referral

Please detail below essential information to outline the patient’s need;*

e.g. Uncontrolled symptoms, complex emotional/psychosocial /spiritual support required.

Please include details of main symptoms/severity and what treatment plan is currently in place*

e.g. syringe driver, summary of medications, type of pain

If same day (emergency admission) – please do not continue this form please call:

Monday – Friday, 8am - 4pm please call Referrals and Discharge on 01926 838889

Anything outside of these hours please call Warwick Myton Reception on 01926 492518 and ask for an Inpatient Unit Senior Nurse or follow the voicemail instructions.

You will not be able to progress any further with this referral.

Inpatient Nurse Led Bed

Patients must be registered with a Coventry or Rugby GP.
Admission will be considered for people who cannot be cared for in their own home or an alternative place of care due to their palliative nursing needs.
Patients can be admitted from the community or hospital and need to be medically stable and not requiring medical intervention.
CHC funding must be agreed prior to admission. Patients should always meet the criteria for fast-track funding.
Patients should be in the final days or weeks of life and have a DNACPR in place.
During a patients stay they will be monitored on a daily basis and if a patient stabilises an alternative place of care may have to be considered.

Reason for Referral

Myton at Home

We understand that many patients want to be cared for in the comfort of their own home, surrounded by family and friends, so our Myton at Home service is designed to enable patients to remain in the comfort of their own home and be supported in their final weeks or days of life.

Our care is offered free of charge and we hope that this information will help you to decide whether this support is right for you.

Respite Bed

The Inpatient Unit at Warwick Myton Hospice offers respite admissions for patients who are aged 18 and over, have a terminal illness and are registered with a GP in Coventry & Warwickshire.

Patient and Carer Wellbeing Service

The Myton Hospice’s Patient & Carer Wellbeing Service works with patients, families and carers to support you to improve your wellbeing and quality of life...

If same day response – please do not continue this form please call:

01788 550085 between the hours of 8.30am-4.30pm Monday to Friday.

Outside of these hours please call the Myton at Home team directly on the following numbers:

Rugby Team - 01788 551516

Warwick/Leamington Team - 01926 838814

You will not be able to progress any further with this referral.

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

Please call our referral team where we will try to direct you to an alternative service:

Monday – Friday, 8AM - 4:00PM please call Referrals and Discharge Clinical Nurse Specialist on 01926 838889

Saturday - Sunday – 9AM - 5:00PM please call our Myton at Home team: For Rugby: 01788 551516 / Warwick: 01926 838814

You will not be able to progress any further with this referral.

Patient first name*

Patient surname*

Patient known as (optional)

Patient date of birth*

Patient telephone number (mobile preferred)*

Patient address*

Please enter the full address and postcode...

Who does the patient live with?

Patient ethnicity (optional)

Patient religion (optional)

Patient GP name (optional)

Patient GP practice*

Patient diagnosis*

Please tell us what the current problems are? How do you think we can help?*

Next of Kin (NOK) Details

Next of Kin first name*

Next of Kin surname*

Next of Kin relationship to patient*

Next of Kin mobile number*

Carer Details

Carer first name*

Carer surname*

Carer address*

Please enter the full address and postcode...

Carer relationship to patient*

Carer mobile number*

Please provide details of existing care package*

Please provide details*

Medical information

Palliative diagnosis*

Prognosis*

Medical history*

Please provide as much detail as you know as this is incredibly helpful to us...

What it the patient’s current clinical situation?*

For example: Heart Failure NYHA Class IV, Liver Mets...

Please summarise any other significant medical and/or mental health problems including any recent or past treatments*

For example: Heart Failure NYHA Class IV, Liver Mets...

What is the patient's native language?*

Please tell us more*

Are there any infection risks? If so please tell us more*

Please tell us more*

What are the patient’s main concerns or issues and do they have any specific goals they wish to achieve through this service?*

Any other medical information you wish for us to know (optional)

Respite request

Which week is requested?*

Please note only one week can be requested at a time, Thursday to Thursday, and a maximum of three months in advance...

Which alternative week is requested?*

Thursday to Thursday, and a maximum of three months in advance...

Referrer details

Referrer first name*

Referrer surname*

Referrer job title*

Referrer location*

Referrer mobile number*

Referrer email*

Please specify where*

Please tell us their name (if known)

Your privacy...

We promise to do our best to keep your details safe and secure, and will only process your data in accordance with the current Data Protection legislation. For further details on how your data is stored visit: https://www.mytonhospice.org/privacy-policy/

Myton at Home

Many people want to have choice over where they are cared for in the last weeks and days of life. Often people wish to stay in familiar surrounds, in their own home.

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

Please call our referral team where we will try to direct you to an alternative service:

Monday – Friday, 8AM - 4:00PM please call Referrals and Discharge Clinical Nurse Specialist on 01926 838889

Saturday - Sunday – 9AM - 5:00PM please call our Myton at Home team: For Rugby: 01788 551516 / Warwick: 01926 838814

You will not be able to progress any further with this referral.

Please ensure that you make a community nurse referral as well as completing this form.

Reason for Referral

If same day response – please do not continue this form please call:

01788 550085 between the hours of 8.30am-4.30pm Monday to Friday.

Outside of these hours please call the Myton at Home team directly on the following numbers:

Rugby Team - 01788 551516

Warwick/Leamington Team - 01926 838814

You will not be able to progress any further with this referral.

Please state what other equipment currently in place*

Therapeutic Day

Our Day Units offer a welcoming, relaxed, yet stimulating atmosphere providing patients with an opportunity to meet and talk to others who are in a similar situation to themselves and access to a structured therapeutic programme of activities.

What are you hoping this individual will gain from this experience?*

Living Well

The Living Well Programme is aimed at enabling people to identify their most significant concerns and priorities, providing a range of support to help manage the changes in their life and to enable them to focus on the things that are meaningful to them.

Patient diagnosis (including current treatment)*

Relevant co-morbidities / past medical history*

Other health and social care professionals known to this person. Please state names and contact details.*

What do you hope the person will gain from attending our Living Well programme?*

Fatigue and Breathlessness

The FAB programme takes place in the Day Unit on each of the Myton sites and is designed to support people who have a life limiting illness which causes fatigue and breathlessness.

Primary diagnosis underlying participant’s breathlessness*

MRC Dyspnoea Scale Score (if known)

Relevant co-morbidities/past medical history*

What do you hope the participant will gain from this course?*

How many of litres of oxegen will the patient need per minute?*

Please ensure that the patient is aware they will need to bring Oxygen for a two hour programme (as well as their travelling time)

Lymphoedema

Our Lymphoedema Service is based at Warwick Myton Hospice and serves both Myton and community patients of Coventry, Rugby and South Warwickshire.

Which part of the body is affected?*

Lymphoedema treatment to date

Cancer diagnosis*

Cancer treatment*

Known metastatic sites (if applicable)

Other medical history*

Medication*

Please tell us more about the patients allergies or sensitivities*

The patient may qualify for a home visit. Please continue the form.

Any requirements specify to patient (e.g. hearing/sight/care needs)*

Quick description of services

Section A

We are sorry but only healthcare professionals can make a referral using this form. Please check "the services that we provide" page for more information about our services and how to refer by clicking here.

Self referral (OLD)

Unfortunately due to the Coronavirus outbreak this service is temporarily suspended, We are really sorry and hope to be back up and running soon. At this moment in time you cannot refer to this service.

Your details

Patient details (OLD)

GP details (OLD)

Inpatient Medical Bed

Reason for Referral

If same day (emergency admission) – please do not continue this form please call:

You will not be able to progress any further with this referral.

Inpatient Nurse Led Bed

Reason for Referral

Myton at Home

Respite Bed

Patient and Carer Wellbeing Service

If same day response – please do not continue this form please call:

You will not be able to progress any further with this referral.

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

You will not be able to progress any further with this referral.

Next of Kin (NOK) Details

Carer Details

Medical information

Respite request

Referrer details

Your privacy...

Myton at Home

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

You will not be able to progress any further with this referral.

Please ensure that you make a community nurse referral as well as completing this form.

Reason for Referral

If same day response – please do not continue this form please call:

You will not be able to progress any further with this referral.

Therapeutic Day

Living Well

Fatigue and Breathlessness

Lymphoedema

The patient may qualify for a home visit. Please continue the form.

Section B

Next of Kin

Section C

Other Healthcare Professionals involved

Section D

Section E

Find out more about the difference your support makes…

Unfortunately due to the Coronavirus outbreak this service is temporarily suspended, We are really sorry and hope to be back up and running soon.

At this moment in time you cannot refer to this service.