Complete your LivingGrief referral - Great Yarmouth & Waveney

Where did you hear about this service?

Please detail how you heard about the service:

I can confirm that the deceased person was known to St Elizabeth Hospice and received care from the palliative care team*

Yes, I can confirm this is true

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

Are you referring yourself or on behalf of someone?*

If you are referring someone else, has the referred consented to the referral?

If they have not consented, please detail why:

If you are referring someone else, please detail your relationship to them

If you are referring someone else please detail your full name:

If you are referring someone else, please detail your contact telephone number:

Full name of bereaved individual seeking support*

Preferred pronouns of person being referred*

He/Him
She/Her
They/Them
Other

Please enter their pronouns, if not listed above

Your full name*

Preferred pronouns*

He/Him
She/Her
They/Them
Other

Please enter your preferred pronouns, if not listed above:

Date of birth*

Address Line 1*

Address Line 2

City/Town*

County*

Postcode*

Primary phone number of bereaved person seeking support*

Email address of bereaved person seeking support*

Preferred method of written contact*

Post
Email

Ethnicity of person being referred*

Gender of person being referred*

Primary Language*

Religion

Do you consider yourself/the person being referred to have a disability?*

If yes, please tell us if you/the person being referred requires any access support

Reason for referral*

Detail issues or concerns that have prompted this referral and how the deceased died (e.g. terminal illness, cancer, COVID-19)

Name of deceased*

Relationship 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/the bereaved receiving care, support or treatment from any other organisation or healthcare professional for this bereavement or any other mental health concern?*

For example, anxiety

If yes, please give details including name/address/telephone numbers of support services you use

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

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):

After this form, you will need to fill in a short self-assessment form to complete the referral. Please indicate who will be filling this in:*

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Complete your LivingGrief referral – Great Yarmouth & Waveney

You have chosen to refer to St Elizabeth Hospice

Referrals for residents in Great Yarmouth & Waveney can only be made for patients aged 18+ known to St Elizabeth Hospice who received care from the palliative care team.

After you have submitted this, you will be directed to complete our short self-assessment form.

You have chosen to refer to St Elizabeth Hospice

Referrals for residents in Great Yarmouth & Waveney can only be made for patients aged 18+ known to St Elizabeth Hospice who received care from the palliative care team.

After you have submitted this, you will be directed to complete our short self-assessment form.

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