Full name
Address including postcode
Telephone number
Email
Name and age of child with cancer diagnosis
Name of all adults with parental responsibility and relationship to the child
Do you or any other adult with parental responsibility have any medical conditions that we may need to be aware of as part of our support and visits, for example epilepsy, diabetes or allergies? If yes, please provide details
Does your child have any siblings? If so please list their name, DOB and whether or not they live at home.
What is your child's cancer diagnosis?
What do you know about your child's diagnosis and treatment plan? If you do not know, it is absolutely fine to write that too
What does your child know about their diagnosis and treatment plan?
Oncology consultant's name and contact details
GP surgery and contact details
Child's community nursing team and contact details
Child's school, contact details and named contact
Have you or your family now or ever been supported by social care? If so, please add your social worker’s name and contact details
Have you had any other agencies helped you in the past? If so, please let us know the details
When visiting your home, is there suitable parking available nearby. If so where is it?
Is the street well lit when going to and from the car?
Are there any pets in your household? Are there any considerations to be given about safety?
Are there any other people that live in your home? Are there any considerations to be given with regard to safety?
Does consideration need to be given to the needs of others within the family home?
Is there good mobile phone signal coverage at your home?
Do you have any other comments about risk?
Is there anything else you would like to let us know that would be useful before we visit?
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