Referral form

Do you know which service you are making a referral for? *

Rachel House

Robin House

At Home Service

Bereavement Service

Don't know

Bereavement Support Referral Form

Please complete this form to refer an individual or family for bereavement-only support to CHAS. The information you share will help us understand what support might be helpful before we contact the family. It helps us decide whether CHAS is the right service, or if another organisation may be better placed to support them. All information provided will be treated confidentially and used solely to assess and provide appropriate support.

Full Name *

Contact Number of referrer *

Email Address *

Organisation, Role and Address (If appropriate)

Name of child who has died *

Was the child previously known to CHAS? *

Yes

Don't know

Child's Date of Birth

Child's Date of Death *

Place of death *

Sex (registered at birth) *

Male

Female

Prefer not to say

Main family contact name *

Main family contact number *

Email address of main family contact *

Family address (including Postcode) *

GP Details *

Reason for referral *

Further information or specific needs

Person requiring support 1

Person requiring support 2

Person requiring support 3

Person requiring support 4

Consent *

I confirm that verbal consent has been obtained, where appropriate, from: the individual requiring support (if aged 16 or over), or the parent/carer with parental responsibility (if under 16), authorising this referral and permitting CHAS to contact, in order to gather, store, and share relevant information electronically with other professionals involved in the support.

Baby's, child or young person's full name *

Date of birth *

CHI (if known)

Sex (registered at birth) *

Male

Female

Prefer not to say

Address of child *

Telephone *

Carer 1 *

Carer 2 *

Names and DOB of any brothers or sisters

Family address

Has the referral been discussed with the family (or with the child/young person, where appropriate)? *

Yes

Who was the discussion with? *

Name of referrer *

Position of referrer *

Address of referrer *

Contact Information of referrer *

Reason for referral for consideration of CHAS services *

Opinion of prognosis, and summary of what has been discussed with the family *

Current medical problems (including current medications) *

Relevant family history *

Any other relevant information *

Professional Involvement

Please add the name of GP plus any other professional involved, e.g paediatrician, pharmacist, named person, lead social worker, community children's nurse / oncology outreach nurse / health visitor.

GP's Name *

Medical Practice *

GP's Telephone

GP's email

Add another professional?

Yes

PI-TitleDescription

Please add the name of GP plus any other professional involved, e.g paediatrician, pharmacist, named person, lead social worker, community children's nurse / oncology outreach nurse / health visitor.

Professional's Name (2) *

Professional's Job Title (2)

Professional's Telephone (2)

Professional's email (2)

Add another professional?

Yes

PI-TitleDescription

Please add the name of GP plus any other professional involved, e.g paediatrician, pharmacist, named person, lead social worker, community children's nurse / oncology outreach nurse / health visitor.

Professional's Name (3) *

Professional's Job Title

Professional's telephone (3)

Professional's email (3)

Parent/Guardian Consent *

Yes, I confirm that verbal consent has been provided by the parent/guardian for the referral to be made and for CHAS to gather relevant medical information from other professionals and hold and share this information electronically.

Name of Parent\Guardian who has given consent *

What is their relationship to the child/young person? *

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