St Clare HospiceEnquire About St Clare Hospice’s Bereavement Support For Your Child

Enquire About St Clare Hospice’s Bereavement Support For Your Child

Young boy is pictured with a sad look on his face while his parent/guardian comforts him.

Make an enquiry about St Clare Hospice’s Children and Young Person’s Bereavement Support

To make sure each child or young person receives the right level of bereavement support, we ask parents, carers and professionals to complete the initial enquiry form below. This helps our Children and Young Person’s Bereavement Support Service team review and triage every request before inviting a full referral.

Once we receive your enquiry, a member of the team will contact you to discuss your child or young person’s needs and confirm whether our service is the most appropriate support.

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

Your details

Your name(Required)

First Last

Your address

Street Address Address Line 2 Town County Postcode Country

Your telephone number(Required)

Your email address(Required)

Your relationship to the child/young person(Required)

About the child/young person

Child/young person's name(Required)

First Last

Their age

Their date of birth(Required)

Bereavement information

The name of person who has died(Required)

Their date of death(Required)

Their relationship to the child/young person(Required)

Please tell us how the child is currently coping and any worries you have about them: (Required)

Consent(Required)

I consent to the collection and use of my child’s personal data for the purpose of my initial enquiry to St Clare Hospice’s children’s and young person’s bereavement support services.

Referrer declaration

I confirm that I have discussed this referral with the child’s parent/carers and they consent to this query being made.

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