Applying to the hospice

Home hospice

If your child suffers from a very serious, non-treatable, life-threatening disease, it is likely the Hospice for Children of Lower Silesia can help.

If you are interested in our help, please send your application with a copy of the last hospital discharge note to the following address:

You can also bring the set of documents in person to the Hospice office or send them by post.

If you have any questions, please call us:

+48 577 651 036

Accepting a child at our home hospice requires a referral (“Skierowanie”) issued by a primary health care phisician or a doctor from the hospital ward:

• the electronic referral (“e-skierowanie”) with the code 2181 (a home hospice for children), or
• the referral, written on the “Skierowanie do szpitala” (“Hospital referral”) form, including:
  • Child’s personal details
  • Diagnosis
  • Details of our Association: Hospicjum dla Dzieci Dolnego Śląska, ul. Benedyktyńska 12, 50-350 Wrocław

After we obtain information about the child’s needs, we will arrange an appointment with a hospice doctor at your home at a convenient time.

Please also attach a signed data protection statement with the following content:

„Zgodnie z art. 7 RODO (ogólnego rozporządzenia o ochronie danych osobowych z dnia 27 kwietnia 2016 r.) wyrażam zgodę na przetwarzanie danych osobowych moich i pozostającego pod moją opieką pacjenta, w tym w szczególności danych dotyczących stanu zdrowia pacjenta, przez Stowarzyszenie Hospicjum dla Dzieci Dolnego Śląska „Formuła Dobra” z/s we Wrocławiu do celów objęcia pacjenta opieką Hospicjum”

and get familiar with the information on personal data processing in the Hospice: Privacy Policy

Perinatal hospice

If you or your relatives are affected by a serious illness of an unborn child, please call us:

+48 792 510 010

or email us:

We provide psychological and spiritual help, as well as doctor’s consultations with our specialist in palliative medicine. We work with gynecologists, obstetricians and neonatology experts from the University Clinical Hospital in Wrocław, as well as with geneticists from the Wrocław Genetic Clinic and the Evangelium Vitae foundation.

We operate under the RAZEM (“Together”) program to provide parents who are expecting the birth of a seriously ill child with comprehensive support.

More information on the perinatal hospice page.

Perinatal Hospice Referral (for manual filling, document in Polish) [PDF, 101kB]

Perinatal Hospice Referral (for computer, document in Polish) [docx, 19kB]

Example completed referral form (in Polish) [PDF, 102kB]

Please also attach a signed data protection statement with the following content:

„Zgodnie z art. 7 RODO (ogólnego rozporządzenia o ochronie danych osobowych z dnia 27 kwietnia 2016 r.) wyrażam zgodę na przetwarzanie danych osobowych moich i pozostającego pod moją opieką pacjenta, w tym w szczególności danych dotyczących stanu zdrowia pacjenta, przez Stowarzyszenie Hospicjum dla Dzieci Dolnego Śląska „Formuła Dobra” z/s we Wrocławiu do celów objęcia pacjenta opieką Hospicjum”

and get familiar with the information on personal data processing in the Hospice: Privacy Policy

You can also bring the set of documents in person to the Hospice office or send them by post.