Bodie’s Bereavement Support Service Referral Form for Professionals

Our services are available for families bereaved of a baby or child aged 24 weeks gestation to 18 years.

Name of referrer *

Job title *

Organisational Name *

Professional email *

Your contact number *

Best time to contact you *

MorningAfternoonEvening

Has the family given consent for the referral to be made ? (If no, we would ask that you contact the family and make them aware you have made a referral to us) *

YesNo

Family details

Please give all family members details including all ages of any sibling being referred and any details of any special educational needs.

Adult 1

Name *

Surname *

Relationship to child *

Sex *

Pronouns

Ethnicity *

Religion

Adult 2

Second Adult - Name

Second Adult - Surname

Second Adult - Relationship to child

Second Adult - Sex

Second Adult - Pronouns

Second Adult - Ethnicity

Second Adult - Religion

Adult 3

Third Adult - Name

Third Adult - Surname

Third Adult - Relationship to child

Third Adult - Sex

Third Adult - Pronouns

Third Adult - Ethnicity

Third Adult - Religion

Adult 4

Forth Adult - Name

Forth Adult - Surname

Forth Adult - relationship to child

Forth Adult - Sex

Forth Adult - Pronouns

Forth Adult - Ethnicity

Fourth Adult - Religion

Sibling information

Sibling 1 First name

Sibling 1 Last name

Sibling 1 Date of birth

Sibling 1 Sex

Does Sibling 1 have any additional needs?

YesNo

If Yes, please give details below:

Sibling 2 First Name

Sibling 2 Last Name

Sibling 2 Date of Birth

Sibling 2 Sex

Does Sibling 2 have any additional needs?

YesNo

If Yes, please give details below for Sibling 2

Sibling 3 First Name

Sibling 3 Last Name

Sibling 3 Date of birth

Sibling 3 Sex

Does Sibling 3 have any additional needs?

YesNo

If Yes, please give details below for Sibling 3

Sibling 4 First Name

Sibling 4 Last Name

Sibling 4 Date of birth

Sibling 4 Sex

Does Sibling 4 have any additional needs?

YesNo

If Yes, please give details below for Sibling 4

Sibling 5 First Name

Sibling 5 Last Name

Sibling 5 Sex

Sibling 5 Date of birth

Does Sibling 5 have any additional needs?

YesNo

If Yes, please give details below for Sibling 5

Family's main address *

City *

Postcode *

Family phone *

Family email *

Name of the child that has died *

Date of birth for the child that has died. *

Date the child died *

To help us look after your referral please tell us when and how the child died *

Brief description of the reason of referral: (What do you think would be helpful for the family) *

Please give us consent to contact you in relation to your referral to Bodie’s Bereavement Service *

YesNo

Consent

Signature *

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Thank you for completing this referral form, we aim to contact families within 28 days of receiving your request.