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, by emailing or by phoning 0800 987 5422.
Full Name of child
Child's date of birth
Parent's name(s) *
Sibling's name(s)
Contact telephone number *
Email address
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
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