Referral Form
This form can be completed by the parent/carer or healthcare professional of any child in the UK who has received a HIE (hypoxic-ischaemic encephalopathy) diagnosis. The information will be used by Peeps (registered charity 1179495) to contact the family, offer relevant support, and keep updated with any services that may be of use to them. Further information can be found on the website www.peeps-hie.org.uk, by emailing info@peeps-hie.org or by phoning 0800 987 5422.

If you would prefer to have this information in a different language or format, please get in touch.

Should you wish to remove your details from our database at any time, please contact info@peeps-hie.org.

Thank you and best wishes
All @Peeps 
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Full Name of child
Child's date of birth
MM
/
DD
/
YYYY
Gender
Ethnicity 
Address
County
Postcode
Parent/carer name 1 *
Relationship to child
Contact telephone number *
Email address
Parent carer name 2
Relationship to child
Sibling's name(s)
Preferred method of contact
Clear selection
HIE Diagnosis (Grade I, II or III) *
Any additional diagnosis?
Referral - please give a brief summary of the reason for the referral and any support that may be required *
Have you/the family received a Peeps Parent Pack?
Clear selection
Name of referrer (if not self-referring as parent/carer)
Professional status
Hospital / Local Authority
Contact telephone number
Email address
Parent/carer aware of referral? *
How did you hear about Peeps?
Clear selection
Submit
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