Self Referral to Hospice Bereavement Services

Self referral to hospice bereavement services

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

Have you been bereaved of someone who had a palliative diagnosis(Required)

Yes

No

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

Your Details

Your name(Required)

First Last

Your date of birth(Required)

Your telephone number(Required)

Your address(Required)

Street Address Town / City County Postcode

Your Religion

Services that interest you(Required)

Please select the service(s) you are interested in.

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

Your relationship with deceased(Required)

Date of bereavement(Required)

Details of the deceased's illness(Required)

(Cancer, MS MND, Other- Please specify )

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)

Authorisation

Signature (type your name)(Required)

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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