Complete your 565 Service referral

I can confirm that the deceased person was living with a progressive disease, life-limiting condition or COVID-19.*

Yes, I can confirm this is true

E.g. cancer, heart failure, kidney disease, MND, MS, Parkinson's disease, Dementia

What illness or condition did the deceased person die from?*

Are you referring yourself or on behalf of someone?*

Please confirm you have parental responsibility:

Yes
No

Please confirm that a person with parental responsibility has consented to this referral:

I confirm the above

Please note that we are unable to accept a referral where consent has not been gained

Has consent been sought from parent/carer with parental responsibility? (please note, we are unable to accept a referral where consent has not been gained).

Please note that this form is aimed at young people aged 16-18. If you are younger than 16, you can still fill in this form, but we will need to know that a parent or carer is aware. Is a parent/carer aware that you are making a referral?

Is the child/young person aware that you are making a referral?

Yes
No

If you have selected no, please detail why:

Please give the full name of the child/young person seeking support:*

Please detail your role/relationship in relation to the child/young person being referred:

What are their preferred pronouns?*

He/Him
She/Her
They/Them
Other

Please enter pronouns, if not listed above

Please give the date of birth of the person being referred:*

Please enter the child/young person's address. Address Line 1:*

Please enter your name:*

Please enter your address. Address Line 1:*

Address Line 2

City/Town*

County*

Postcode*

Do you live at this address too?*

Yes
No

Does the parent/carer live at the same address as the child/young person?*

Yes
No

If no, please detail the different address below:

Street Address Address Line 2 City County Postcode

Please detail the parent/carer name:*

Parent/carer contact telephone number:

Please give your full name:*

What are your preferred pronouns?*

He/Him
She/Her
They/Them
Other

Please enter pronouns, if not listed above

Please give your contact telephone number:*

Please give your email address:*

Enter Email Confirm Email

Please give your date of birth*

Primary contact number:*

Parent/carer name:

Parent/carer contact number:

Do you give permission for us to contact your parent/carer?

Yes
No

What is your preferred method of written contact*

Post
Email

Ethnicity of person being referred:*

Tell us your ethnicity:*

Gender of person being referred:*

Tell us your gender:*

Primary language for person being referred*

What is your primary language?*

Tell us if the person being referred has a faith or religion:

Tell us your faith/religion:

Do you consider the child/young person to have a disability or any additional needs that might be useful for us to know about?*

Do you consider yourself to have any additional needs that you think is important for us to know about?*

If yes, please tell us what support is needed:

Reason for referral*

Detail issues or concerns that have prompted this referral (e.g. difficulties processing loss, anger, low mood, difficulties sleeping, poor school attendance). How the deceased died (e.g. terminal illness, cancer, COVID-19). How do you think our service can support you?

Name of deceased*

Relationship to deceased*

Relationship of child/young person to deceased*

Deceased date of birth:

Date of death:

Place of death:*

Were they known to any hospice or a specialist palliative care team?*

If yes, detail which hospice

Are you receiving care, support or treatment from any other organisation or healthcare professional?*

(e.g. social care services, mental health services, 4YP, Suffolk Young Carers, private counselling).

Is the child/young person receiving care, support or treatment from any other organisation or healthcare professional?*

(e.g. social care services, mental health services, 4YP, Suffolk Young Carers, private counselling).

If yes, please give details including name/address/telephone numbers of support services being used

For example, mental health service. If so, please give details e.g. name, address, telephone numbers

Do you give permission for us to make contact with the named services?

Yes
No

Does the person with parental responsibility give permission for us to make contact with any named services?

Yes
No

Does the person with parental responsibility give permission for us to make contact with any named services?

Yes
No

Do you currently attend school/college?

Yes
No

If the child/young person attends school or college, please let us know which one:

If yes, which school/college do you attend?

Are you able to attend sessions in the hospice at Ipswich on Foxhall Road?

Yes
No

Is the child/young person able to attend sessions in the hospice at Ipswich on Foxhall Road?

Yes
No

If no, please state why:

If you are unable to attend hospice, where would you prefer to access support?

School
Online

If they are unable to attend hospice, where would they prefer to access support?

School
Online

Please let us know if there are any days or times that would not be suitable for attending sessions:

Would the child/young person be interested in attending a bereavement support group?

Yes
No

If you select yes, we will get in touch with further information on when the next group is available.

Are there any safeguarding concerns relating to the child/ young person you are referring?

Yes
No

Is there anyone else in the family that has been referred to our service?

Yes
No
Unsure

If yes, please let us know their name(s):

If yes, please give further details:

Is there anything else that you think is important for us to know?

CAPTCHA

You have chosen to refer to

St Elizabeth Hospice's 565 Service for young people

You have chosen to refer to

St Elizabeth Hospice's 565 Service for young people

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