Referral Form

This form can be completed by the parent/carer or healthcare professional of any child in the UK who has received an H.I.E. (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 within our Privacy Policy, by emailing info@peeps-hie.org or by phoning 0800 987 5422.

Referred child

About the child

Please provide us with some information regarding the child and diagnosis.

Forename ^*

Surname ^*

Date of Birth ^*

Gender ^*

Ethnicity

Child's Contact details

Please enter the primary contact details of this child.

Address Line 1 ^*

Address Line 2

City ^*

County ^*

Post Code ^*

Details of diagnosis

Please provide us with information regarding this child's diagnosis.

HIE Diagnosis (Grade I, II, III) ^*

Any additional Diagnosis?

Details of siblings

If the referred child has siblings, you may provide details here, so we can make sure to take them into account during our support. Please leave blank in not applicable.

Forename

Surname

Date of Birth

Forename

Surname

Date of Birth

Forename

Surname

Date of Birth

Forename

Surname

Date of Birth

Forename

Surname

Date of Birth

Parent details

Primary carer

Please provide us with details of the primary carer/parent.

Title ^*

Forename ^*

Surname ^*

Relationship to child? ^*

Primary Phone Number ^*

Email address ^*

Is your address the same as the referred child? ^*

Additional carer?

Optionally, you may also provide details of an additional carer/parent.

Title

Forename

Surname

Relationship to child?

Primary Phone Number

Email address

Is your address the same as the referred child?

What type of support are you looking for?

Mental Health Support (counselling / trauma therapy)

Peer Support

Financial Assistance

General Support

Other (please specify)

Other support required

Preferred Language?

How would you prefer to be contacted? ^*

Have you/the family received a Peeps Parent Pack? ^*

How did you hear about Peeps? ^*

By submitting these details I hereby acknowledge that Peeps may use the submitted details for the purpose of processing my referral ^*

Peeps on Twitter

; @peeps-HIE @PeepsHie ·

27 Sep 1839574124009591022

We were recently asked if we had resources that could support a family who didn’t have English as their first language. Yes we do! There’s our @reciteme toolbar (as the video clip shows, it’s easy to navigate!) and also we can match with a counsellor / therapist in a chosen…

; @peeps-HIE @PeepsHie ·

27 Sep 1839545670400639361

Thank you to everyone who came to see our stand yesterday at the @babylifeline #MatSafety2024 Conference, to the brilliant speakers and panels, and of course the Baby Lifeline team who must have put so much work in to organising the event.

It was great to learn, share and…

; @peeps-HIE @PeepsHie ·

26 Sep 1839277010054418617

This is what we all want to see - a reduction in H.I.E. rates. Wonderful to meet @CatherineH_RM and @Sblackwell192 who work so hard to achieving this with their teams. The impact for families is huge 💕 #MatSafety2024 @BabyLLTraining

Referred child

About the child

Child's Contact details

Details of diagnosis

Details of siblings

Parent details

Primary carer

Additional carer?

Peeps Updates

Peeps on Twitter