Child Bereavement Referral Form

Child Bereavement Referral Form

Child Bereavement Support Groups
Name of Child

First NameLast Name
Gender
Ethnic origin/religion
Date of Birth

DayMonthYear
Date
Name of parent(s)/carer

First NameLast Name
Does this person have parental authority
Relationship to the child
Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Email
example@example.com
Daytime contact number

Area CodePhone Number
Mobile number (s) parent/carer

Area CodePhone Number
Mobile number of child if applicable

Area CodePhone Number
Prefered means of contact
Name of person referring child

First NameLast Name
Agency and position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number

Area CodePhone Number
Email
example@example.com
Circumstances of the death (include specific information such as names, relationship to child, cause of death etc.)
Date of death

DayMonthYear
Date
Reason for referral (concerns about the child e.g. behavioural changes)
Other agencies involved (if applicable) e.g. School Welfare Support, Social Care, CAMHS
School/College Attending
School/College Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
School telephone number

Area CodePhone Number
Named person at the school to contact
Medical condition(s)/allergies (if any)
Relevant medication
Disability (if any)
Who does the child live with and family composition
Any other issues or risks (including to staff) we need to know about
Any other information that may be useful
Please indicate any days or times when your child would not be available, e.g. clubs
Please confirm that child/parental/carer consent for this referral has been obtained
Date

DayMonthYear
Date
For more information please contact Bereavement Co-ordinators
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