Bodie’s Bereavement Support Service - Family Referral Form

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

Please choose from our current bereavement services below (Tick all that apply) *

1-1 counsellingCreative Grief for Bereaved Mums - peer support group which meets monthly Chips and a Chat for Bereaved Dads - peer support group which meets monthly

Title

Name *

Preferred first name

Surname *

Parent Date of Birth *

Relationship to child *

Sex *

Pronouns

Ethnicity *

Religion *

Adult 2 First Name

Adult 2 Surname

Adult 2 Relationship to child

Adult 2 Sex

Adult 2 Ethnicity

Adult 2 Religion

Sibling first name

Sibling last name

Sibling age - date of birth

Sibling sex

Sibling pronouns

Does this child have any additional needs?

If Yes, please detail them here:

Sibling 2 First Name

Sibling 2 Last Name

Sibling 2 date of birth

Sibling 2 Sex

Sibling 2 pronouns

Does Sibling 2 have any additional needs?

If you have answered yes to Sibling 2 having additional needs please detail them here:

Sibling 3 First Name

Sibling 3 Last Name

Sibling 3 date of birth

Sibling 3 Sex

Sibling 3 pronouns

Does Sibling 3 have any additional needs?

If you have answered yes to Sibling 3 having additional needs please detail them here:

Sibling 4 First Name

Sibling 4 Last Name

Sibling 4 date of birth

Sibling 4 Sex

Sibling 4 pronouns

Does Sibling 4 have any additional needs?

If you have answered yes to Sibling 4 having additional needs please detail them here:

Address *

City

Postcode *

Mobile *

Email *

Name of the child that has died *

Date of birth of your child that has died *

Date your child died *

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

Brief description of the reason of referral: (what would be helpful to you at this time) *

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 21 days of receiving your request.