Professional Referral to Hospice Bereavement Services

Professional referral to hospice bereavement services

CONFIDENTIAL All relevant fields must be completed fully as an incomplete form will lead to a delay in processing.

Has the person been bereaved of someone who had a palliative diagnosis?(Required)

Yes

No

This form is only suitable for referring people who have been bereaved of someone who had a palliative diagnosis. A referral has not been created.

Bereaved Person's Details

Person's name(Required)

First Last

Person's date of birth(Required)

Person's telephone number(Required)

Person's address(Required)

Street Address Town / City County Postcode

Services recommended(Required)

Please select the service(s) appropriate for the bereaved person

1-2-1 Bereavement support

6-week Group Bereavement programme

Bereavement Walking Group

Bereavement Drop in café

Children’s bereavement work

Complementary Therapy

Assessment for Bereavement counselling (at least 12 weeks post bereavement) - please note that a holistic needs assessment will be completed by a member of the Community Outreach Team in the first instance. This will be by either a Social Worker or a Nurse. The assessment outcome will inform the suitable level of intervention provided by our team.

Walking Group

Details of Bereavement

Name of decesased(Required)

First Last

Person's relationship with deceased(Required)

Date of bereavement(Required)

Details of the deceased's illness(Required)

(Cancer, MS MND, Other- Please specify )

Referrer's Details

Name of referrer(Required)

First Last

Job role(Required)

Referrer telephone number(Required)

Referrer email address

Communication Needs

Are there any communication needs we need to be aware? e.g. speech difficulties

Is an interpreter required?

Yes

No

Detail the interpreter needs (language, dialect, speech recognition)(Required)

Consent

Has the bereaved person consented to this referral?(Required)

Yes

No

Legals / Authorisation

Signature (type your name)(Required)

This field is hidden when viewing the form

Date of Submission

Your email address

You must provide an email address if you'd like to receive a copy of this form.

I declare that the information that I have provided is correct.(Required)

Yes

Professional Referral to Hospice Bereavement Services

Professional referral to hospice bereavement services

Bereaved Person's Details

Details of Bereavement

Referrer's Details

Communication Needs

Consent

Legals / Authorisation

Bereavement Referrals

Self Referral to Hospice Bereavement Services

Bereavement Referrals