Referral form - Children's bereavement/Nicky's Way - 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 child (aged 4-18 years)
Other

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

Child/Young 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

Parent/Guardian Name and Contact Number(Required)

GP practice

If other, please state:

Name of school(Required)

Additional children

Would you like to add a second child/young person?

Yes
No

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:

Name of school(Required)

Would you like to add a third child/young person?

Yes
No

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:

Name of person who has died(Required)

Relationship

Cause of death

Date of death

Name of school(Required)

Is this referral for yourself?(Required)

Yes
No

Details of referrer

Name(Required)

First Last

Job title / relationship

Telephone number(Required)

If you are not the child/young person wishing to be referred, is the child/young person you are referring aware you are doing so?

I am the person wishing to be referred
Yes
No

Please do not continue without consent for referral.

If you are not the parent/guardian please state relationship with child or young person(Required)

I am the child/young person's parent/guardian

Has parent/guardian agreed to this referral?(Required)

Yes
No

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?

Are there any safeguarding concerns?(Required)

Yes
No

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

Do you/the child/young person have a social worker?(Required)

Yes
No
Unknown

Please provide name and telephone number

Is your or the child/young person's school aware of this referral?(Required)

Yes
No

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

Has the person requesting a referral had or is having support from children and adolescent mental health services (CAMHS)?(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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You can learn more about data protection and change your preferences at www.stnicholashospice.org.uk/yourdata.

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Referral form – Children’s bereavement/Nicky’s Way

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Referral form – Children’s bereavement/Nicky’s Way

What we do

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