Child Bereavement Referral Form
Child Bereavement Support Groups
Name of Child
*
First Name
Last Name
Gender
Ethnic origin/religion
Date of Birth
*
-
Day
-
Month
Year
Date
Name of parent(s)/carer
*
First Name
Last Name
Does this person have parental authority
*
Yes
No
Relationship to the child
Address
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Email
example@example.com
Daytime contact number
*
-
Area Code
Phone Number
Mobile number (s) parent/carer
-
Area Code
Phone Number
Mobile number of child if applicable
-
Area Code
Phone Number
Prefered means of contact
Name of person referring child
First Name
Last Name
Agency and position
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
-
Area Code
Phone 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
-
Day
-
Month
Year
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 Name and Addresss
Street Address
Street Address Line 2
City
County
Postal / Zip Code
School telephone number
-
Area Code
Phone 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
*
Yes
No
Date
-
Day
-
Month
Year
Date
For more information please contact Bereavement Co-ordinators
Submit
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