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Printed at: 11:31:27 / 21-09-2021

Home Leave Agreement

Please note, this page is printable by selecting the normal print options on your computer.

What is Home Leave?
Home leave is a period of time in which your child is able to go home with you whilst still being under the care of the hospital and your child’s named consultant.

Who decides on Home Leave?
This is a joint decision with their named consultant, the senior nurse on duty and you as their parent/carer. It is important that your child’s health and well being is considered in the decision
making process and all aspects of their care will be considered with you in making this decision.

What if I am worried about taking my child on home leave?
Home leave is a voluntary option only and if you are concerned about any aspects of taking your child home at this time then please ensure that these concerns are discussed with the medical and nursing team caring for your child. It is perfectly alright to stay in hospital either until you feel more confident or right up until your child is discharged from the hospital’s care.

Who is responsible for my child whilst on home Leave?
As their parent/carer this responsibility sits with you until they return to the ward area.

Home Leave Agreement
Name of Child:
MRN:
DOB:
Name of Consultant:
Name of Senior Nurse:
Agreed Terms of Home Leave
Date agreed:
Time of leaving:
Time to return:
Where child will reside whilst on home leave:
………………………………………………………………………………………………………………………………………
Any exclusion as to visits outside of hospital (i.e. school, public places):
………………………………………….………………………………………….………………………………………….
One off agreement 
Ongoing agreement 
Please Record further dates of Home Leave as necessary:

 

Equipment Required for Home Leave:

Please list here equipment required to ensure continued care at home (consider NG tubes/pH paper, special milk feeds etc):
………………………………………………………………………………………………………………………………………
……………………………………………
Medications required to take home:
………………………………………………………………………………………………………………………………
Given to parent/carer 
Name of Parent/Carer:
………………………………………
Signature of parent Carer:
……………………………………..
(Copy to be kept in patient notes)

Telephone Numbers
Ward 5: 01908 996377
Ward 4: 01908 996367
Hospital Switchboard: 01908 660033
Matron for Children’s Services: 01908 996587
‘References can be supplied for this information contained within this information if required from the Author.’