ERIC constipation support service - referral form This field is hidden when viewing the formAccess codeThis field is hidden when viewing the formCall stageThis field is hidden when viewing the formRecord type IDThis field is hidden when viewing the formClinician referenceThis form is only for use by clinicians within NHS Trusts that are using the ERIC Constipation Support Service.If you can see this message, you have accessed this form without using the correct URL - please contact your manager.Parent / carer detailsParent / carer name(Required) First Last Parent / carer name(Required) First Last Parent / carer email(Required) Enter Email Confirm Email Parent / carer phone number(Required)Does the parent / carer have any communication needs?(Required)NoYesPlease give details of the parent / carer's communication needs(Required)Child detailsChild's NHS number(Required)Age of child(Required)0-12 months12345678910111213141516171819Macrogol laxatives and the under-fives(Required) In this service, ERIC advisers will support the parent/carer in using macrogol laxatives, which are not specifically licenced for disimpaction for the under-fives. This doesn’t mean that they are harmful or unsuitable, and they are recommended for disimpaction for children of this age in the NICE guidelines and by NHS England. Please confirm that you and the parent/carer are aware of this and happy to proceed. Gender of child(Required)BoyGirlChild (gender unknown)Case details(Required)Are you aware of any existing safeguarding concerns related to this parent / carer or child?NoYesPlease give details of any relevant safeguarding concernsPlease ask the parent / carer to rate the following statements on a scale of 1 - 5, with 1 meaning 'strongly disagree' and 5 meaning 'strongly agree'.I feel confident in managing my child's bowel problems(Required)12345I know where to go to get more information, advice and guidance(Required)12345What actions have you previously taken to support your child's bowel problems? Accessed resources online Talked to my child's education provider Talked to to my child's education provider Supported my child to follow an effective toileting routine Supported my child to follow an effective toileting routine Encouraged my child to drink plenty of water-based fluids Encouraged my child to drink plenty of water-based fluids Other Other (please give details) Other action already takenParent / carer terms and conditionsPlease ask the parent / carer to confirm that they understand and accept the arrangements for this servicePlease read the following to the parent / carer (or show them your screen) and ask them to confirm I understand that ERIC is a registered charity which provides bladder and bowel health services for NHS patients, and I agree to a referral being made to ERIC to support my needs. I understand that NHS Cornwall & Scilly Isles holds personal information about me, which might include information shared with them by other agencies. I agree that NHS Cornwall & Isles of Scilly may share the information they hold about me with other NHS bodies, my GP, adult services, social care and voluntary sector organisations including ERIC. I understand that my normal rights under the Data Protection Act are not affected by this agreement. Please confirm that the client is prepared for the support service: The client has committed to three calls with an ERIC advisor The client understands that if they miss a scheduled call twice, the case will be closed The client has been prescribed enough laxatives for a full disimpaction
