Chaplaincy referrals

The Chaplaincy at Birmingham Women’s and Children’s Hospital can support referrals of patients and or family members.

We can offer a listening ear, prayers or blessings, spiritual play activities for the children etc. If you would like to refer a patient or family member to us, please fill in the form below and it would be our privilege to offer them support.

Note: Questions marked by * are mandatory

In accordance with the General Data Protection Regulation (GDPR), in force from 25 May 2018 by submitting this form you agree for your data to be used for the purposes of processing your award nomination only.

*This is a mandatory field. Name of patient

Name of family members with patient

*This is a mandatory field. Your name

*This is a mandatory field. I am

*This is a mandatory field. Your contact details, phone and or email

*This is a mandatory field. Why are you referring to us?

*This is a mandatory field. Do the family / patient know you are referring to us? (It is ok if they don’t know yet)

*This is a mandatory field. Any other information you think would be helpful for us to have to support them more effectively? Age, condition, ward, admission date?

*This is a mandatory field. We are unable to give you any updates without the permission of the patient or family. If the patient or family give permission, would you like any updates?

Thank you, we look forward to supporting them.

* Spam Guard: Is water wet or dry?

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