Peeps' Coffee Pot
Our "Coffee Pot" is a fund set up from a parent's suggestion, so that contributions can be made to buy a brew for a fellow H.I.E. parent who is in hospital. (Peeps will facilitate this by buying a voucher from the fund, for a suitable coffee shop/retailer, depending on what is in or near the hospital). 

The "coffee pot" is available for any family in the UK who has been touched by H.I.E. and has referred in to Peeps (this is so we can measure and monitor our activity and support). If you haven't already completed our referral form, you can do this here. 

To request a "coffee" (you can spend the voucher on your drink of choice, or cake - we don't judge!) or nominate someone, please complete this short form, we'll do the rest!

If you need any help completing the form, or would prefer it in a different format, please contact us by emailing info@peeps-hie.org or phoning/texting 07838197945.

The information on the form will only be used for the purpose of providing a voucher, we will not share your details.

If we can help support in any other way, please don't hesitate to get in touch.
Sign in to Google to save your progress. Learn more
Your name (First name and surname).

Your contact email address.
Your contact telephone number. 
Have you completed a Peeps' referral form previously?
Clear selection
Is the request for yourself (that's absolutely fine and we actively encourage this, we all deserve a little self care)? 
Clear selection
If nominating someone, please let us know their name.
Hospital and ward you/your nominated person are currently in.
Length of current hospital stay.
Please let us know your preferred choice for a voucher (e.g. Costa, Starbucks, M&S) - please note that some franchises may not accept all vouchers, so do check if not sure. 
Email address you'd like the voucher sending to.
If you'd like to add a message (if to your nominated person), please pop it below and we'll pass it on. 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms