Bereavement Self Referral Form
Thank you for contacting us, you only need to complete what you feel comfortable: sharing this information helps us to understand your situation so we can offer you the most appropriate bereavement support.
Details of person requiring support
*
First Name
Last Name
Preferred name
NHS number
Gender
*
Please Select
Male
Female
Non-binary
Transgender
Genderfluid
Prefer not to say
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Postcode
Marital Status
*
Please Select
Married
Civil Partnership
Single
Divorced
Separated
Widowed
Prefer not to say
Ethnicity
*
Main Language
*
Contact number
*
Please enter a valid phone number.
Format: (00000) 000000.
Email address
example@example.com
Preferred method of contact
*
Please Select
Phone
Email
Text
Is it safe to leave a voicemail or send messages?
*
Please Select
Yes
No
About Your Bereavement
Name of the person who has died
*
First Name
Last Name
Relationship to you
*
Their date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of death (approximate if unsure)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of death
*
Please Select
Home
Hospital
Hospice
Care home
Other
Was your loved one known to Dove House Hospice
*
Yes
No
How are you coping?
Please tell us a little about how your bereavement is affecting you and what kind of support you are hoping for (for example; someone to talk to, group support, complementary therapies to help manage symptoms)
*
Current support
Are you currently receiving support from any of the following:
*
GP
Counsellor/Therapist
Mental health service
Another charity
Family/Friends
No current support
Other
Wellbeing and Safety
Do you feel safe right now?
*
Please Select
Yes
No
Not sure
If you indicate that you are not safe, we may contact you sooner or encourage you to seek urgent support from your GP or 111 mental health support
Have you had thoughts of harming yourself recently?
*
Please Select
Yes
No
Prefer not to say
Are you experiencing any of the following? (tick all that apply)
Low mood/depression
Anxiety or panic
Sleep difficulties
Difficulty coping day to day
Loneliness/isolation
Guilt or anger
Flashbacks or intrusive thougths
Poor appetite
Financial worries
Other
Practical Needs / Accessibility
Do you have any needs we should be aware of?
Disability or mobility needs
Language or interpreter required
Cultural or religious considerations
Preferred apppointment times
Other
Submit Referral
Should be Empty: