Referral form - Adult bereavement - St Nicholas Hospice Care website

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Date

Email(Required)

A confirmation of receipt of this referral will be sent to you upon completion. Please provide an email address here.

Enter Email Confirm Email

Reason for referral

Bereaved adult
Other

Please call the Hospice on 01284 715572 to discuss this further.

Person information

Name(Required)

First Last

Date of birth(Required)

Contact address(Required)

House name/number and street Address Line 2 Town County Post Code Country

Telephone number(Required)

GP practice

If other, please state:

Please do not fill out this form any further, and instead contact our Clinical Admin team on ***

Is this referral for yourself?

Yes
No

Referrer details

Name(Required)

First Last

Job title / relationship

Telephone number(Required)

Please tell us a little about the person/people who have died

Name of person/people who have died(Required)

Relationship

Cause of death

Date of death

If you are not the person wishing to be referred, is the person you are referring aware you are doing so?(Required)

I am the person wishing to be referred
Yes
No

Please do not continue without consent for referral.

Has the person being referred declined to share their records with other healthcare professionals?(Required)

Yes
No
Unknown

Why does this person not wish us to share records with other healthcare professionals?

Can we leave an answerphone message on the numbers provided?(Required)

Yes
No
Unknown

If no, please tell us why

Are there any safeguarding concerns?(Required)

Yes
No

Please contact the Hospice on 01284 705252, or 01284 766133 if out of hours, to discuss.

Why is the person requesting a referral seeking support now?(Required)

Has the person requesting a referral had or is having support from mental health services?(Required)

Has the person requesting a referral had suicidal thoughts or attempts?

Yes
No
Unknown

Please provide details

Is your/their GP aware?

If these suicidal feelings are current, contact your/their GP, and/or emergency services via 999 and/or the Samaritans on 116 123 and/or First response on 0808 196 3494.

We will still process this referral but ask that you prioritise yours or their safety with immediate effect.

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Referral form – Adult bereavement

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Referral form – Adult bereavement

What we do

Protecting your data

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