Lanarkshire ICJ Referral
Referral Type
Clinical
Self
Other
Other Referral
Referrer
Referrer
Referrer Email
Referrer Contact Telephone
Referrer Role
Please select...
Benefits Advisor
Cancer Navigator
Carer
Clinical Nurse
Community Worker
Consultant
District Nurse
Friend
GP
GP Link Worker
HCSW
HMP Shotts
ICJ
Relative
Social Worker
Other
SPC
Client Details
First Name
Last Name
Email
Telephone
Street
Town
Postcode
How did you hear about ICJ
Please select...
Community Hub
Family Member
Friend
GP Consultant
HMP Shotts
Leaflet
Link Worker
Nurse
Other
Poster
Social Media
Support Group
Client Profile
Preferred Contact Method
Telephone
Email
Text
Post
CHI No
DOB
Interpreter Required
Yes
No
Language
Gender
Please select...
Male
Female
Transgender
Non Binary
Not Supplied
Other Useful Info
Risk Assessment, Home Visit Not Advised etc
Emergency Contacts
Date of Referral Consent
Date the patient gave their consent for ICJ Referral Verbal Consent acceptable
Diagnosis
Date of Diagnosis
This just needs to be an estimated date
Type of Cancer
Other Cancer Type
Pathway Stage
Initial Diagnosis
Prehabilitation
Start of Treatment
During Treatment
End of Treatment
Follow Up
Recurrence
Transition to Palliative Care
In Palliative Care
Other Health Conditions
BASRIS
Please select...
Yes
No
Upload BASRIS
SR1
Please select...
Yes
No
Upload SR1
If you are unable to upload completed BASRIS and SAR1 the forms should be sent to icjadmin@vaslan.org.uk
Client Aware
Please select...
Aware of Diagnosis and Prognosis
Aware of Diagnosis but NOT Prognosis
Not Aware of Diagnosis and Prognosis
Not Applicable
Date of Next Clinical Review
Status
Please select...
Being Assessed
Accepted
Completed
Rejected
Cancelled
New Referral
Contact Information