Bassetlaw Hospice
Bassetlaw Hospice

Support and Wellbeing Centre - Self-Referral Form

Support and Wellbeing Centre

The team at the Support and Wellbeing Centre aim to support patients in the Bassetlaw area who have been diagnosed with a life limiting condition and are struggling with physical, emotional or psychological symptoms.

Please complete the details below and one of our dedicated team will be in touch to discuss how we may be able to support you.

Self-Referral Form

Please tick if registered with a Bassetlaw GP

Please tick to allow us to access your medical records

Please do not provide anything too sensitive here, like specific health details, or your credit card number.

We do not support SPAM and we would never sell your information to anyone. Any correspondence is strictly confidential. We will only use the above information to contact you about your referral.