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Confidential enquiry self-referral form

If you’d like to enquire about our services for yourself or someone else, please fill out the form below and our team will be in touch within three working days.

If you’re enquiring on someone else’s behalf, please make sure you have their consent. Completing this form doesn’t commit you to using our services, and all information will be kept confidential.

Healthcare professionals should NOT use this form to refer patients. Instead, Hertfordshire healthcare professionals should use the PCRC referral route and Buckinghamshire healthcare professionals should use the SPA referral route.

Prefer to speak to someone? Call us on 01923 60 60 30.

Are you submitting this form for you or someone else?

For myself

For someone else (family or friend)

For someone else (in a non-clinical professional capacity)

Your details

You’re completing this form on behalf of someone else (family or friend), please start by entering your own details below. In the next section, you’ll be asked to provide the details of the person who may need our services.

Your name (as the referrer)

Title First Last

Your phone (as the referrer)

Your email (as the referrer)

Your details

You're completing this form on behalf of someone else in a professional capacity. This means the form is intended for non-clinical professionals or organisations to complete on someone’s behalf - for example, a social prescriber, older people’s group, or cancer support organisation. Healthcare professionals should not use this form to refer patients. (Instead: Hertfordshire: use the PCRC referral route. Buckinghamshire: use the SPA referral route).

Your name (as the referrer)

Title First Last

Your phone (as the referrer)

Your email (as the referrer)

Details of the person who may need our services

Please provide the details of the person who may need our services. To help us process the enquiry quickly, make sure their name and address match the information held by their GP. There’s no need to include any personal medical information on this form - our clinical team will collect all necessary details when they get in touch.

Their name (as known by the GP)

Title First Last

Their date of birth(Required)

Their email address

Their phone number

Their address (As known by the GP)(Required)

Street Address Address Line 2 Town / city County Postcode

Their NHS number (if known)

Services required (if known)

Rennie Grove Peace offers a range of services to support people from the point of diagnosis. Our support may vary depending on where an individual lives, but we’ll always do our best to connect them with the right help. If you know which services might be helpful for the person you’re enquiring on behalf of, please indicate them below. If you’re not sure, that’s absolutely fine - you can leave this section blank. A member of our clinical team will be in touch to discuss their needs and help find the support that’s right for them.

Date of bereavement

Your details

To help us process your referral as quickly as possible, please ensure that your name and address match those held by your GP. Please do not include any personal medical information on this form - our team of clinical experts will gather the necessary medical history from you when they get in touch.

Your name (as known by your GP)

Title First Last

Date of birth(Required)

Email address

Phone

Address (As known by the GP)(Required)

Street Address Address Line 2 Town / city County Postcode

NHS number (if known)

Services required (if known)

Rennie Grove Peace provides a comprehensive range of services from the point of diagnosis. If you are aware of the specific services that may be appropriate, please indicate them below. If you are unsure, you may leave this section blank. A member of our clinical team will be in touch to discuss your needs and recommend suitable support.

Date of bereavement