St Clare HospiceBereavement Support Referral for Children and Young People

Bereavement Support Referral for Children and Young People

A teenager is seen with her head pressed against the sofa with a sad, tired look on her face.

Submit a referral for your child

Thank you for completing the initial enquiry to St Clare Hospice’s Children and Young Person’s Bereavement Support Service. Following our review, we now invite you to complete the full referral form.

We understand that sharing more detailed information can feel difficult, especially at such a challenging time. Thank you for trusting us with this information.

The more we understand about your child or young person’s experiences and needs, the better we can offer safe, sensitive and tailored support.

Download our guidance document to help you complete this form. If you need any support at any stage, please don’t hesitate to get in touch.

Download guidance form

Please note that a separate referral form must be completed for each child or young person, even if you are referring more than one child from the same family.

About the child/young person

Child/young person's full name(Required)

First Last

Child/young person's preferred name(Required)

First Last

Their date of birth(Required)

Their ethnic background(Required)

Their religion(Required)

Their home address (including postcode)(Required)

Street Address Address Line 2 Town County Postcode Country

School / college / sixth form address (including postcode)(Required)

Street Address Address Line 2 Town County Postcode Country

Name of the school / college / sixth form they attend(Required)

If you have a contact at their school / college / sixth form, please provide their name, job title and contact details:

GP's name(Required)

GP address (including postcode)(Required)

Street Address Address Line 2 Town County Postcode Country

If this referral is linked to another referral to the Children and Young Person's Bereavement Support Service, please state the other child/young person's name:

Parent/carer details

Main parent/carer's full name(Required)

First Last

Relationship to the child/young person(Required)

Home address including postcode (if different from above)

Street Address Address Line 2 Town County Postcode Country

Telephone number(Required)

Email address(Required)

Additional parent/carer details (if applicable)

Emergency contact details (required for safeguarding and emergencies)

Name of emergency contact (if different from above)

First Last

Relationship to child/young person(Required)

Telephone number(Required)

Alternative telephone number

Referrer's details (if different from above)

Referrer's full name

First Last

Referrer's organisation and role (e.g. teacher, GP, social worker)

Telephone number

Email address

Bereavement information

Name of person who has died(Required)

Their relationship to the child/young person(Required)

Their date of birth(Required)

Their date of death(Required)

Their cause of death (if known and appropriate to share):

Please provide some more details about their relationship with the child (i.e. lived together, close contact etc.):(Required)

Please provide any further details about their death that you think we should know (i.e. circumstances, child’s involvement/awareness of what happened etc.):

Funeral and rituals

Was there a funeral, memorial or cultural/religious ceremony?(Required)

Yes

Did the child/young person attend?(Required)

Yes

If no, do you know what was explained to them?

If yes, what do you understand of their experience?

Child's understanding and beliefs about death

Please provide details of what the child knows about what happened:(Required)

What do they think or believe has happened to the person who died?(Required)

Has the child expressed any worries, misunderstandings or questions that you have found hard to answer?(Required)

Child's current wellbeing

Please provide details of how you feel the child is managing day-to-day (i.e. at home or school):(Required)

Have you noticed any changes in their behaviour, mood, sleep, appetite or friendships?(Required)

Yes

Are you aware of any known risks or safeguarding concerns (e.g. self-harm, neglect, abuse)?(Required)

Yes

If yes, please provide details:

Support already in place

Please provide details of any previous bereavement support the child has received:(Required)

Please provide details of any professional support being received (e.g. CAMHS, social services etc):(Required)

Additional needs

Please provide details of any Special Educational Needs, disabilities, medical conditions or allergies:(Required)

Please provide details of any languages spoken and if an interpreter is required:(Required)

Is there anything else you feel is important for us to know about the child?:

Further information

Is there anything else you would like to tell us about the child/young person’s experience of their grief?

Parent/Carer consent

Parent/Carer signature

Date

Referrer declaration (if applicable)

Referrer signature

Date

Photography and media consent

Group artwork or photographs may be used for St Clare Hospice marketing and promotional purposes. Please indicate your consent below.

Consent

I consent to the appropriate use of photographs and/or videos of my child/young person for marketing and promotional purposes.

I do not consent.

Data protection

We will never pass on your details to any other organisation to use for their own purposes. You can find out about how we use and look after your data at: stclarehospice.org.uk/privacy-policy

And finally

At St Clare, we offer a range of supportive therapeutic spaces for bereaved children and young people. Much of the support we offer is in group settings, where children can share their experiences alongside others who understand. As someone who knows this child well, please indicate what you feel might best support them at this time. Please note that the final decision about support will be made by the Clinical Lead for the Children and Young Person’s Bereavement Support Service.

Please tick all that you feel may be appropriate.