Accessibility tools

Accessibility tools

OneCall 24/7 specialist advice line
Call Fundraising
Call Main Office
Log In
Basket (0)

St Elizabeth Hospice

Donate

How we can help
Zest
- What is Zest?
- How you can support
  - Shop
  - Volunteer
  - Donate
  - Fundraise
- 24hr Advice0800 567 0111calls are free from a BT landline.
About us
- About us
- News
- 24hr Advice0800 567 0111calls are free from a BT landline.
Support us
- Support Us
- Events
- Donate
- 24hr Advice0800 567 0111calls are free from a BT landline.

menu

Complete your LivingGrief referral

You have chosen to refer to St Elizabeth Hospice

_______________________

We can only accept online referrals from those living in East Suffolk & who are mourning a loss from a progressive or life-limiting condition or COVID-19.

This includes conditions such as cancer, heart failure, kidney disease, MND, MS, Parkinson's disease, Dementia or COVID-19.

If you have had a bereavement from a different cause, such as loss of a baby, child, adult or suicide, please go to the LivingGrief Hub here for tailored support.

If you live in Great Yarmouth & Waveney, call us to refer: 0300 303 5196
If you need to refer your child or family, please call 0300 303 5196 to make a direct referral to the 565 Service, aimed at supporting children through bereavement

_______________________

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

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?*
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*

Day
Month
Year
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:

Day
Month
Year
Date of death:

Day
Month
Year
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
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:*
CAPTCHA

Back to LivingGrief homepage

Sign up to receive monthly updates

Here when you need us

Terms and Conditions
Privacy Policy
Cookies
Sitemap
Contact

© Copyright St Elizabeth Hospice (Suffolk) 2023

A company limited by guarantee and not having a share capital Registered Charity No. 289154

Website by Itineris

Share your story